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Can facility design improve worker productivity? Can it make learning easier, help advance scientific discovery, improve the bottom line or speed up the healing process? There is a growing movement toward believing that spaces can be designed to have positive impacts on those who use them. The outcomes of such evidence-based design would be particularly important in a health care setting, as hospital administrators, doctors, nurses, medical equipment manufacturers, planners and architects explore ways to improve health care delivery and medical outcomes.
The debate over evidence-based design has been swirling around the health care field since Roger S. Ulrich’s pioneering research 20 years ago. His study showed a difference in recovery rates between two groups of patients — one that looked out on a brick wall and another that looked onto a stand of trees. The patients who had the bucolic view required less time for recovery, were less negative, and required fewer and less-potent drugs.
Evidence-based design advocates believe that outcomes improve when the physical, cultural and operational atmosphere supports patients and their families throughout hospitalization, medical visits, healing and bereavement. The guiding philosophy is to develop a space that engenders uplifting feelings of peace, hope, joy, reflection and solace. Motivating this philosophy is the research that shows these factors play a considerable role in the physical, emotional and spiritual healing process.
The cornerstone of evidence-based design is data. And the data that need to be collected go well beyond the typical information gathered during hospital design programming. Evidence-based design looks beyond the number of rooms needed, departmental adjacencies or equipment lists. It can focus on operational issues, such as understanding the current care-giving environment from a functional point of view, and then learning how the hospital or specific department wants to function in the future. This information can then serve as a basis for design decisions and metrics put in place to measure performance.
A good example is the new emergency department (ED) at Ball Memorial Hospital in Muncie, Ind. Over the last decade, visits to EDs nationwide have jumped significantly — almost 25 percent. Long waits are the norm for non-life-threatening ED visits and the No. 1 complaint of patients of emergency services. Ball Memorial Hospital wanted to improve the patients’ experience, reduce waits significantly and establish itself as the area’s choice for emergency care. The motive was simple. At Ball Memorial Hospital, more than half of the patients admitted to the hospital enter through the ED. A thriving and efficient ED would only make the facility stronger and more viable.
Ball Memorial Hospital conducted a “think differently meeting” with its architect where all previous assumptions about ED delivery were challenged. Some radical ED goals were set during the meeting, including reduced or eliminated waiting time; elimination of on-call rooms; a family-focused care experience; private “guest” rooms, not curtained spaces; technology such as bedside registration; support spaces in each private room; elimination of chaos; streamlining of operations and hotel-like amenities, including interior design elements, a night concierge and a coffee bar.
Today, when patients enter the 22,300-square-foot ED at Ball Memorial Hospital, a receptionist greets them and they are escorted to one of 35 private patient rooms. Instead of curtains, the rooms have walls and doors and include amenities such as televisions and phones, as well as the medical equipment most patients need in emergency care.
The layout redefines the process of ED patient care. It not only enhances patient comfort by improving privacy and efficiency, it also helps prevent the spread of infectious diseases. The interior design integrates vibrant color, a variety of textures, and lighting and movement throughout the space to make patients feel comfortable in the emergency setting and create a new image for Ball Memorial Hospital.
The new $5.6 million facility opened in July 2003. Early results from only a few months of data already show an 18 percent increase in ED visits, from an average of 130 patients per day before the change to 153 now. The chaos is gone, and praise from patients is the rule rather than the exception.
The hospital has also identified multiple categories of expected improvements and is in the process of tracking metrics to provide evidence of the performance of the design and operational solution. These measurements are focused on three areas: patient experience; staff, squad and physician experience; and improved functionality.
To measure the total patient experience, metrics concerning wait times or delays for six sequences from arrival to exit are being gathered. Length-of-stay information is being measured. Also tracked are rates of patients leaving against medical advice; perceptions about privacy, chaos, patient and family experience; and comfort.
To measure the work experience for the staff, squad and physicians, metrics such as ancillary testing turnaround, availability of supplies, the staff’s pride in its work, chaos and overall squad perception are being gathered. And to measure the functionality of the new ED, accuracy of registrations and lost charges are being tracked. Lastly, to gauge overall awareness and support of the ED within the hospital itself, metrics such as bed availability and first-time bed placement as well as appropriateness of admission are being gathered.
Beyond Color and Comfort
For some time, designers have sharply improved the visual cues in a health care setting using warmer colors, natural light, artwork and other healing symbols. The physical manifestations of evidence-based design include many of these touches. But evidence-based design calls for an intense look at and response to many of the staffing and operational issues within hospitals, such as throughput, functional adjacencies, location of support space, technology, staffing levels and care procedures. This approach can also help identify where non-value-added steps exist in the care delivery process and where bottlenecks occur.
The medical goal of evidence-based design is to minimize many of the inherent problems that patients and practitioners face. Most hospitals address these issues on an ongoing basis but within the context of a traditional hospital environment where procedures and practices are often institutionalized and difficult to change. One of the early adopters of the evidence-based design approach to health care delivery is Clarian Health Partners Inc., Clarian, Ind. Clarian sought to design a new cardiac comprehensive critical care (CCCC) unit at Methodist Hospital that combined existing critical care and coronary medical step-down units located at another one of its hospitals.
But before embarking on an innovative physical design — the merging of two separate groups and new care procedures which were met with skepticism — Clarian wanted to better understand what nurses really did on the existing care units. According to Ann Hendrich, a health care consultant and former nurse executive and senior vice president for Clarian’s Methodist campus, 1,000 hours of nurse activity were videotaped. Astonishingly, this study revealed that only 10 percent of a nurse’s time was spent caring for patients. Most of the caregiver’s time was spent on “hunting and gathering” tasks, such as looking for linens and supplies. The study also revealed that nurses walked an average of three to six miles on each shift.
This revealing look at how time was spent and on what tasks made it clear what functions needed to be closer to the patient rooms to minimize traveling time and distance and to maximize time available for patient care.
This data was the key to developing a “future-state” patient room and CCCC unit. The new 56-bed unit was designed within two existing floors and completed in 12 months at a cost of $6.2 million, or $137 per square foot. That’s comparable to the cost of more traditional facilities at the hospital.
The most important of the innovations that reshaped the space was to decentralize care giving. Nurses’ stations were moved from a central location to nurse-server units located outside patient rooms. These spaces, with computers and supplies, are visible from the patient rooms. Nurses no longer need to walk back and forth from a traditional station. Nurses spend more time on patient care and less time on looking for supplies and other materials. Direct patient care has grown to represent the majority of a nurse’s day.
The new CCCC unit also includes enhancements to the patient environment. All patient rooms are private and large — 450 square feet — with 120 square feet of family space. This is almost twice as much space as in a typical private patient room. Room amenities include a sleep sofa for 24-hour visitation, small refrigerator, locker space for personal belongings, and telephone with private voice mail and Internet connection. Personal restrooms are located near the patient. And patients have control over noise, temperature and privacy. Interior corridor windows are electronically charged and, with a flip of a switch, become opaque.
The design balances the high-tech equipment needed for a CCCC unit with a high-touch atmosphere. The patient and family have much greater control over the environment.
Adjusting to a New Paradigm
Some of the nurses, physicians and staff were skeptical about combining the two units into one and the major changes that were made. In the first year that the unit was open, 30 nurses left, finding it difficult to make the adjustment. But over time many returned, and the unit has become a much sought-after assignment.
Statistics and anecdotal evidence gathered since the unit’s opening in 1999 show that:
- Patient falls are down 75 percent because of the unit’s decentralized design, allowing for better observation of patients and the ability for beds to be rolled near restroom facilities.
- Acuity-adaptable patient rooms, equipment integration and other design features reduced patient transfer 80 percent, resulting in a savings of $2 million a year.
- Patient dissatisfaction dropped from 6.7 percent to 2.7 percent.
- Design of the CCCC unit helped reduce staff by 16 percent
- Staff productivity has increased. Nurses comment regularly on the convenience of supplies and equipment.
An evidence-based design approach has special relevance in health care architecture, where both operations and design must work together to meet health care delivery objectives in a dynamic environment. However, its basic premise of gathering quantifiable information for decision-making and testing the results quantifiably make it useful to other building types where occupant metrics are applicable. Evidence-based design is one more tool to use to shape behavior and drive results through the architectural and planning design process.
A Close Eye on Building Design Increases Productivity for Health Care Giant
With Kaiser Permanente’s nearly 900 owned and leased facilities throughout the country, maintaining design and function uniformity with some local preferences can be a challenge. But with every building the health care system builds and renovates, Kaiser facility staff study that project’s impact on every aspect of business, especially the impact on productivity. The result is an evolutionary process toward greater productivity.
As vice president of national facility services for Kaiser Permanente, Thomas Heller takes advantage of the fact that the facility department is a single entity for the health care giant’s national system.
“We are involved in the design of all the buildings in our program and have at our disposal all our other prior buildings to study,” Heller says. “Because we manage the existing buildings and the construction process, we learn as we grow.”
And grow Kaiser does. The health care system owns 583 buildings at 46 million square feet and leases another 304 buildings. At present, Heller is managing 800 capital projects in California alone.
What Heller has found over the years is that all operational issues, such as air temperature and elevator maintenance, are important to enhancing productivity, but building design is where the most significant strides can be made. Three key areas of continual adjustments are department adjacencies, location of critical means of circulation and ergonomics.
“We do post occupancy surveys and watch closely what the interaction is between departments in existing buildings,” Heller says.
He and his staff study computer models to plan traffic flows and determine where the most effective place would be for stairways.
“Effective department interaction just doesn’t happen on a single floor; a lot of interaction is between floors and the most effective way to go between them is the stairway,” he says.
One area where Kaiser made big changes is physicians’ offices and exam rooms. The old system had physicians offices next to two or three exam rooms, clustering these modules throughout the floor. But in reality doctors weren’t always just using their exam rooms and were spending time walking to other exam rooms not in their cluster.
Now, physicians’ offices are placed on the perimeter where they can get natural daylight and the exam rooms are all in the interior. Now physicians can easily access all of the exam rooms.
“It doesn’t give us more space — that is, we can’t fit any more exam rooms in, but it does make for a more efficient, productive system,” he says.
Along the same lines, to avoid having some operating rooms (OR) sit vacant and have others overscheduled, ORs have become general-purpose rather than specific-purpose ORs. Making them general-purpose rooms has meant making them larger. But that is in part because equipment has also gotten much larger.
— David Kozlowski, senior editor
AIA Studies Spatial Perceptions
Earlier this year, the American Institute of Architects (AIA) announced that it was embarking on groundbreaking research to establish how the brain experiences the built environment. The AIA established the Academy of Neuroscience for Architecture, which will explore this question under two initiatives, one with the Salk Institute and the other with the U.S. General Services Administration and the National Institutes of Health.
The purpose of the research is to prove scientifically that a relationship exists between design and human health, well-being, and worker productivity. The results of this research could affect the way workplaces and buildings are planned and designed. A growing body of data from evidence-based design in the health care field supports the notion that design can affect patient recovery and safety as well as caregiver morale and productivity.
According to Fred H. Gage at the Salk Institute’s Laboratory of Genetics in La Jolla, Calif., the Academy wants to prove the hypothesis that “the environment and the structure we live in affect our brain and our brain affects our behavior.”
The Academy is working with GSA’s Public Building Services (PBS) group to explore stress and the workplace. The study will gather data from 70 PBS employees. Once baseline data is collected, workplace variables will be changed — lighting, HVAC, noise, privacy levels, aesthetics, etc. — while reactions are measured through a small monitor worn by participants. The monitor will track heartbeat and brain activity. An arm patch will collect sweat to measure hormonal activity and biological balance.
Ongoing research in so-called neuroarchitecture will continue throughout this decade before the effects of environments on users can be understood with some scientific certainty.
Increasing Productivity Requires Different Strategies for Different Functions of Health Care
HCA sees the productivity handwriting on the wall and it reads, we are all getting older. That means more patients and an increase in health care services, but it also means less hospital staff, especially in this day of nurse shortages. And all this can affect productivity.
“There’s a national nurse shortage that is affecting everyone so we want to make sure our nurses are not only more productive but also happier in their work,” says Tom Gormley, vice president of design and construction. And of the things he has to consider is the fact that the nurses themselves are aging.
HCA is using facility designs that utilize newer lift technologies that help nurses move patients around and newer bed technologies that help patients stand.
Plus, HCA is looking at how much quality time a nurse gets to spend with a patient versus how much time is spent doing perfunctory job duties such as getting supplies and dispensing medicines. To maximize the quality time and minimize time spent doing perfunctory things, HCA decentralizes supply stations so that every wing of every nurses’ station has a mini-supply room that, during the busiest times of the day, nurses can use instead of the central supply station at the nurses’ central station.
To reduce time spent on paperwork, supplies are all bar coded. As supplies are used, they’re scanned and the information is sent immediately to central supply.
A similar system is used for medication. Patients’ medications are scanned before being administered. A computer then checks to make sure it’s the right medication, given at the right time and at the right amount. It also notifies central supply so inventories can be kept.
“Nurses used to have to use this sticky-paper system that left them with labels stuck to their uniforms and information misplaced or lost,” Gormley says.
But making the whole system more productive extends beyond the duties of nurses and other health care staff. It has meant centralizing, rather than decentralizing some functions. HCA now uses a Wal-Mart-like warehouse for its supplies that is linked to the barcode system used in every hospital, clinic and medical office building. And centralization in the name of productivity also extends to the business offices. HCA built 10 revenue service centers in the last few years. These centers don’t organize supplies, but instead insurance forms and payroll for each hospital’s business office.
Both these trends have meant the hospital can devote more square footage to patient care, and more time, too.