Probably the most famous description of the impact of buildings on people came not from an architect or a researcher studying workplace performance, but from a politician, British Prime Minister Winston Churchill: “First we shape our buildings; thereafter, they shape us.”
No segment of the facilities market has taken that observation more to heart than health care facilities. Today, the concept of evidence-based design is drawing interest because it moves beyond the general idea that the physical environment affects occupants: It seeks to gauge the impact of specific designs on productivity, employee and patient morale, and patient outcome.
Evidence-based design stems from the recognition that the physical environment can have a measurable influence on our well-being, especially in health care. “A properly designed environment is part of the course of care,” says D. Kirk Hamilton, founding principal with Watkins Hamilton Ross Architects in Houston and associate professor with the Center for Health Systems and Design at Texas A&M University.
Under the banner of evidence-based design, a growing number of facility executives, architects and designers are applying rigorous, peer-reviewed studies of the facilities impact on patient outcomes. Evidence-based design is “the critical thinking of the architect, working together with an informed client, to make design interpretations on the basis of reliable evidence from research,” says Hamilton.
Today, experts are completing studies to determine how different aspects of a facility — such as décor, the placement of sinks and bathrooms, or the use of overhead pages — affect patients’ health. The effects are measured by looking at statistics such as the rate of nosocomial infections — those that patients acquire while in the hospital — or the number of medication errors and the length of patient stays. Improving these measures should translate into an overall enhancement of patients’ well-being.
This approach differs from the traditional mindset of many designers and architects, says Rosalyn Cama, president of Cama Inc. and board chair of the Center for Health Design in Concord, Calif. Most architects are guided by principles of good design, as well as their own knowledge and intuition, but they also have to comply with codes and regulations, she says. They rarely have done true, academic research that shows when the environment puts patients at harm and when it helps them.
That’s changing. In 2000, a handful of health care organizations, working with the Center for Health Design, launched the Pebble Project. Member organizations examine the impact of the health care facilities they’re constructing. The goal of each research initiative is a report that shows — in a manner that can be replicated by others — whether the money spent on the facility did achieve intended results. For instance, a study might evaluate whether making all patient rooms private lowers the rate of nosocomial infections.
Why “Pebble Project?” A pebble thrown into a pond creates ripples across the water, says Cama. The 24 hospitals now participating in the project hope to create ripples that will dramatically change the way health care facilities are designed and operated.
The Pebble Project organizations hope that evidence-based design helps accomplish three objectives: promote healing; recruit and retain employees; and reduce operating costs, Cama says.
To achieve those aims, the starting point is for facility executives and architects to identify project goals, says Mike Kastner, director of building services and construction management with Lakeland Regional Health Systems, St. Joseph, Mich.
For instance, the goal may be reducing patient falls, which often occur when a patient tries to reach the bathroom at night. Disoriented and tired, the patient may trip and fall.
An architect taking an evidence-based-design approach might start with the knowledge that a facility similar in size to the one being designed will experience 20 falls annually. The goal might be to reduce that number to five. One approach is to place the patients’ beds nearer to the bathroom and keep a night light on, says Kastner. Once the facility is in operation, the architect and health care organization would document how the design influenced the number of falls by patients.
Evidence-based design can mean different things to different people, so identifying its general parameters is important. For starters, evidence-based design doesn’t mean simply spending money on lavish amenities. “It’s nice to have a nice lobby, but can you say it’s having an influence on making people well?” asks John Balzer, vice president of facility planning and development with Froedtert & Community Health System, Milwaukee, a member of the Pebble Project.
In addition, evidence-based design is about more than trying to reduce the stress patients experience while they’re in the hospital, although that’s certainly an important subset of the discipline. However, the field is more expansive, with such goals as reducing medication errors and the length of the average hospital stay.
Finally, evidence-based design means not using a cookbook approach to building design. Because every facility is built within a specific set of requirements and constraints, each requires a tailored approach. The goal is for architects and facility executives to intelligently adopt or adapt the research that’s been done and apply it to the project they’re working on.
Health care organizations around the country are doing just that.
Bronson Methodist Hospital in Kalamazoo, Mich., built a 287-bed replacement facility that opened in 2000. All patient rooms are private. Today, the rate of hospital-acquired infections is 11 percent lower than it was in the old facility, says Sue Reinohl, vice president, business development. A single infection can add more than a week to a hospital stay.
Froedtert & Community Health System added a new 118-bed, in-patient facility, says Balzer. The new break rooms contain windows — the first time the organization has provided windows in staff areas. “The windows were reserved for the public, while the staff got the back of the house.”
Froedtert’s nursing vacancy rate is about 4 percent. The national average is about three times that. Although it would be difficult to prove that windows alone have helped Froedtert retain nurses, they are one tool in the box. “We feel strongly enough about this that we will take one patient room (on a wing) out of service to use the windows for the staff,” says Balzer.
In Michigan, Lakeland Regional Health Systems is building a 142-bed addition to its facility, which houses 250 beds. The new facility will incorporate several principles from evidence-based design. For instance, patient-room toilets will be located to minimize falls, and supply stations will be near nurse stations to reduce the distances nurses must walk each shift.
Once the building is complete, Kastner and his colleagues will study more than 30 metrics, including the length of patient stays, the number of patient transfers and nurses’ promptness in responding to call buttons.
Parrish Medical Center in Titusville, Fla., which opened in 2002, incorporates several elements identified as being critical to a healing environment by the Center for Health Design, says George Mikitarian, president and chief executive officer.
For instance, to ensure quiet patient areas, Parrish has nearly eliminated public address pages. Parrish also has done away with the traditional nurses’ station. Instead, nurses work from alcoves that are located within patient wings and equipped with computers, phones and storage space. This puts nurses closer to patients and reduces the time needed to answer calls.
The design appears to be winning over patients. In January 2003, respondents to a patient satisfaction survey ranked 12 of 16 areas higher than 90 percent.
The management team at St. Alphonsus Regional Medical Center in Boise, Idaho, is adding a nine-story tower that is being constructed using evidence-based design, says vice president Susan Gibson.
St. Alphonsus also created a prototype floor with 40 rooms designed using evidence-based design in its current facility and has monitored differences between these and older rooms, says Gibson. For instance, the renovated rooms feature materials and finishes with high sound-absorbency ratings. Patients in the new wing ranked the quality of their sleep a 7.3. That compares to a 4.9 ranking by patients in traditional rooms.
Applying evidence-based design is not without challenges.
One is the dearth of architects experienced in the discipline. “A lot understand the words and concepts, but not many have designed buildings based on it,” says Kastner.
Cost is another significant challenge. Many facilities that incorporate evidence-based design principles require a larger initial investment. Private rooms, for instance, are more expensive to build than shared rooms, although they can lower the rate of nosocomial infections.
As a result, facility executives trying to make the case for evidence-based design often need to calculate both the initial construction cost and the cost to operate the facility over several years. Savings from lower rates of nosocomial infections, fewer medication errors or more efficient staff processes can allow an organization to recoup the higher investment.
One notable study on the trade-off between the higher initial cost and lower ongoing costs associated with evidence-based design is known as “The Fable Hospital” study. “The Business Case for Better Buildings,” as the study is formally known, was published in Frontiers of Health Care Management.
The research team analyzed studies on evidence-based design currently under way to determine likely construction cost increases when a hospital uses evidence-based design. They compared that with the estimated change in ongoing operating expenses. The name of the fictitious, 300-bed health care facility is Fable Hospital.
The researchers found that constructing a hospital using evidence-based design concepts added approximately $12 million to construction costs. For instance, all patient rooms are private, have larger bathrooms with double doors and feature sinks placed near the doorway to encourage caregivers to wash their hands.
Within a year, anticipated operational savings more than compensated for the extra investment. For example, patient falls can cost about $10,000 each. Nationally, the median rate of falls is 3.5 per 1,000 patient days. The study estimated that this number would drop by 80 percent as a result of locating beds closer to the bathroom, using a monitoring system that alerts nurses when a patient is out of bed, and putting double doors on bathrooms. The result at Fable was an estimated savings of $2.5 million annually. And that total doesn’t include any reduction in litigation costs due to the reduced number of falls.
Another challenge with evidence-based design is the need to compromise when two goals collide. For instance, the nursing staff at Saint Alphonsus wanted hard-surface flooring in work areas because spills are common. Carpet would require more frequent cleaning, which would interrupt the nurses as they did their jobs.
“You can’t compromise efficiency by having someone come in and clean the floors,” Gibson says. “But from an aesthetic and noise point of view, we would prefer carpet.”
To reach the dual goals of efficiency and noise reduction, Gibson and her staff are pairing hard-surface flooring with ceiling tile that’s very high in sound absorbency.
It’s important to note that not all evidence-based design principles boost costs. For instance, ceiling tiles that absorb sounds and reduce noise levels can cost about the same as materials that are less sound-absorbent. However, sound-absorbent tiles can create a quieter environment and dramatically boost patient satisfaction.
Finally, another challenge, albeit one which will dissipate over time, is the fact that much of the hard, rigorous research on evidence-based design is just now being done. As a result, it can be difficult to find existing studies that stand up to questioning.
“In a lot of what’s been described as evidence-based design, the evidence is not as strong as one would like; it’s more anecdotal,” says Tom Heller, vice president of facility services with Oakland, Calif.-based Kaiser Permanente.
For instance, there’s little rigorous research showing that the color of patient rooms or the presence of music can influence healing, says John Kouletsis, director of planning and design with Kaiser. “You can say that seems to make sense, but there’s little hard science.”
On the other hand, data is accumulating in other areas, such as the impact of different materials, like low-VOC paints, on patients, says Heller. “Our approach is to continually scan what’s being said and done, and weed through to find what’s real.”
Clearly, evidence-based design is gaining ground, and more rigorous studies will soon be completed. As the body of data grows, advocates for evidence-based design contend that facility and real estate professionals will be compelled to evaluate and apply it. “Now that we know there is research, there’s an obligation to use it in the same way that we expect an aircraft engineer to use the best research,” says Hamilton. “It’s a moral issue and a patient safety issue.”
Karen Kroll, a contributing editor to Building Operating Management, is a freelance writer who has written extensively about real estate and facility issues.