DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE …

© 2007 The Center for Health Design®

DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE

The Quality Colloquium Harvard University

August 21, 2007

Blair L. Sadler, J.D. Former President & CEO

Rady Children’s Hospital, San Diego, CaliforniaSenior Fellow, Inst. For Healthcare Improvement

Vice Chair, Center for Health Design


Today’s Learning Objectives

Learn about published articles on evidence-based design that correlate with improved clinical outcomes, patient satisfaction and staff recruitment and retention.

Understand the compelling business case (capital costs vs. operating savings and increased revenue) for building optimal hospitals.

Understand a continuum of changes that you can make to improve care


Institute of Medicine - 1999

“…Serious and widespread quality problems exist throughout American Medicine. These problems…occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for- service systems of care. Very large numbers of Americans are harmed as a result…”

Institute for Healthcare Improvement, 2001


Institute for Healthcare Improvement, 2001

Facts

The patient safety problem is large.

It (usually) isn’t the fault of healthcareworkers.

Most patient injuries are due to systemfailures.


Risks

Medical errors:Harm more than 1.5M year in U.S.Institute of Medicine, 2006

Hospital-acquired infections: 2M a year in U.S.; 92,000 dieModern Healthcare, 2006

Nursing turnover: 20% per yearJCAHO, 2002


Connecticut Nurses’ Association

Healthcare Workers

75% feel the quality of nursing care at their organization has declined in the past two years.

50% feel exhausted & discouraged when they leave work.

40% feel powerless to effect change necessary for safe, quality patient care.


PATIENT CENTERED

TIMELY EFFICIENT

EFFECTIVE

SAFE

EQUITABLE

QUALITY

Components of Quality


QUALITY

FURNISHINGS

LIGHTTE

XTURECOLOR

MATERIALSSCALE

PRIVACY/CONTROL

WAYFIN

DING

ACCESS TO

NATURE

AROMA

SOUN

D

ART

SAFETY &

SECURITY

Components of Quality


Making a Key Connection

Most healthcare environments are more stressful & riskier for patients, family members, & staff than they should be.They actually make these problems worse!

Conversely, improved design can measurably improve care and the work environment


Levels of Transformational Change

Patient

Microsystems

Organization

Environment

AimsPromisesResults

PeopleProcessesInformation

ITHuman ResourcesFinanceLeadership

FundingCommunityGovernment r

SafeEffectiveEfficient

Patient CenteredTimely

Equitable

Six Domains of

Quality


Big Issues in the Next Ten Years of Improvement

The interactions between patients and the system of careThe organization context of careThe environmental context of care

Donald M. Berwick, MD, MPPInstitute for Healthcare Improvement

1st Annual Forum for Improving Children’s Health CareMarch 12, 2002


“In service industries, the environment is the most objective

and visible sign of respect for the patient, family and staff.”

Leonard L. Berry Author, Discovering The Soul of Service


“Although the premise that physical environment affects well-being reflects

common sense, evidence-based design is poised to emulate evidence-based medicine as a central tenet for healthcare in the 21st

century."

Colin Martin The Lancet

August 2000


Construction Cost Estimates:$35 billion by 2009

Source: FMI

Healthcare Building Boom

• Aging facilities• Aging population• Bed shortages & capacity bottlenecks


Evidence-Based Design Research


Evidence-based design is the deliberate attempt to base building decisions on the best available evidence.


EBD Research Literature Search - 1998

• Johns Hopkins University• Rubin & Golden meta-analysis• 84 studies• Published report



• Robert Wood Johnson Foundation• Texas A&M, Georgia Tech• Ulrich and Zimring meta-analysis• 600+ studies• Published report, abstracts



Rigorous studies link the environmentto outcomes in four areas:

1. Reduce patient stress2. Reduce staff stress3. Improve safety4. Improve quality


EBD Research Patient Stress Scorecard

Reduce stress, improve quality of life and healing for patients and families

Reduce noise stressReduce spatial disorientation

Improve sleep Increase social support

Reduce depressionImprove circadian rhythms

Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients & families

Provide positive distractionPatient stress (emotional duress, anxiety, depression)

Ulrich & Zimring, 2004


EBD Research Staff Stress Scorecard

Reduce staff stress/fatigue, increase effectiveness in delivering care

Reduce noise stress Improve medication processing and delivery times

Improve workplace, job satisfaction Reduce turnover

Reduce fatigue Work effectiveness; patient care time per shift

Improve satisfaction



EBD Research Patient Safety Scorecard

Improve patient safety and quality of care

Reduce nosocomial infection (airborne)(contact)

Reduce medication errors Reduce patient falls

Improve quality of communication (patient- staff)(staff - staff)

(staff - patient)(patient - family)

Increase hand washing compliance by staff Improve confidentiality of patient information



EBD Research Quality Scorecard

Improve overall healthcare quality and reduce cost

Reduce length of patient stayReduce drugs (see patient safety)

Patient room transfers: number and costsRe-hospitalization or readmission rates

Staff work effectiveness; patient care time per shiftPatient satisfaction with quality of care

Patient satisfaction with staff quality



Research Conclusions

Many designs make hospitals more stressful and riskier for patients and staff.

A LOT of good evidence is available.

The evidence supports that good design can reduce stress and harm.


Research Conclusions Immediate action

• Provide larger single-bed rooms• Provide variable acuity rooms/reduce transfers• Reduce noise to reduce stress & improve sleep• Provide stress reducing views of nature• Develop efficient way finding systems• Improve ventilation and lighting• Provide positive distractions through the arts• Design to reduce staff walking & fatigue• Provide equipment to reduce staff injuries• Install visible/accessible hand washing facilities


What is The Center?

• Non-profit research & advocacy organization

• Work began in 1988• Research, education, advocacy, support


The Pebble Project®


Purpose

• Use evidence-based design• Create a ripple effect• Provide examples• Establish a research model• Start a dialogue• Support a community


The Pebble Pioneers --IMPACT

• 40 active provider partners• 4 corporate partners• 2 alumni• Various project types• Different stages of design


Pebble Project Benefits

• Research methodology• Research facilitation• Marketing opportunities• Learning workshops• Consulting & technical expertise• Recognition• Community


Architecture & Interior Design: Shepley Bulfinch Richardson & Abbott

Bronson Methodist Kalamazoo, MI

• $181 million• December 2000• $42 million less for new construction


Bronson Methodist Design Features

• Access to nature• Control• Positive distractions


Bronson Methodist Areas of Measurement

• Turnover• Outcomes• Length of stay• Cost per unit of service• Waiting times• Satisfaction• Organizational behavior • Productivity


Bronson Methodist Selected Data: Safety & Operations

• 11% decrease in infections• $500,000 savings a year in transfers• Increased market share• 87% occupancy


Bronson Methodist Selected Data: Consumer Preferences

48

54

2622

413736

2428

35

26 24 22

30

0

10

20

30

40

50

60

Dec'98 Dec'99 Dec'00 Dec'01 Nov'02 Nov'03 Nov '04

Bronson Competito


Bronson Methodist Selected Data: Satisfaction

• 5.4% nurse turnover• Increased employee satisfaction• 96.7% patient satisfaction


Bronson Methodist Selected Data: RN Turnover

0%

5%

10%

15%

20%

1998 1999 2000 2001 2002 2003 2004 Q2 2005

BMH National Benchmark Best Practices National Benchm

Source for National Benchmark: The Advisory BoardSource for Best Practices: ANCC


Bronson Methodist Selected Data: Overall Turnover

0

5

10

15

20

25

2001 2002 2003 2004 Q2 2005Bronson National Avg Best Practice


Bronson Methodist Selected Data: Patient Satisfaction

Inpatient Experience Better Than Expected

3032343638404244464850

1996 1997 1998 1999 2000 2001 2002 2003 2004


Bronson Methodist Performance Results


The Bronson Lesson

A better building enhanced the well- being of its patients, families and staff.

It also facilitated the cultural transformation that they were trying to achieve.


The Fable Hospital

How much does a better building cost?

To answer that, we invented The Fable Hospital.

Based on our Pebble Project® partners’measured experience using Evidence-Based Design (EBD).


The Fable Hospital

• 300-bed regional medical center• Urban site• $240M replacement facility• Values: quality, safety, patients, families, staff, cost, value, community responsibility


Unusual Culture

• Obsessed with quality and safety• Driven by values• Patient focused• Family friendly• A good corporate citizen• Determined to be eco-sensitive• Willing to benchmark• Want to be held accountable


EBD Design Features

• Oversized, windowed, single rooms• Variable acuity rooms• Decentralized, barrier-free nursing stations

• Additional hand-washing facilities• HEPA filters• Ceiling lifts


Methodist Hospital Indianapolis, IN

Architecture & Interior Design: BSA LifeStructures

Edward Heart Hospital Naperville, IL

Architecture & Interior Design: Matthei Colin Associates


EBD Design Features, (cont’d)

• Double-door bathroom access• Healing art, music, and gardens• Consultation spaces• Patient education center• Staff support facilities


Bronson Methodist Hospital Kalamazoo, MI

Architecture & Interior Design: Shepley, Bulfinch, Richardson & Abbott


The Fable Hospital

Detailed Construction Cost Estimates

Example

+ $12 Million(5% of project cost)


Savings & Revenue Example - Transfers

19,466 patient stays x $250 = $4,866,500 $4,866,500 x 80% = $3,893,200 savings

The Fable Hospital

• Average cost of one transfer is $250-$300; • Fable’s acuity adaptable rooms helped reduce transfers by 80%.

• Actual Pebble Project data from Methodist found a 90% decrease.


Savings & Revenue Example - Patient Falls

300 beds at 80% occupancy = 240 beds = 87,600 patient days/1,000 x 3.5= 306 falls/year x $10,000 = $3,066,000 Reduced by 80% = $2,452,800 savings

The Fable Hospital

• Unlitigated average cost is $10,000.• National median is 3.5 falls/1,000 patient days.

• Fable’s unit & room design helped reduced falls by 80%.

• Similar to Pebble Project data from Methodist Hospital.


Savings - Infections

4/month at $4,000 unlitigated cost= $192,000/year x 42% = $80,640 savings

The Fable Hospital

• 5-10% of patients get infections; average cost is $4,000

• Fable’s single bed rooms, HEPA filters, & location of hand-washing facilities helped reduce infections by 4 patients a month.

• Reimbursed 58% of additional costs from infections.

• Actual Pebble Project data from Bronson found 4-6 patients a month reduction.


The Fable Hospital

Savings & Revenue (One-Year Savings)

Fewer Patient Falls

Fewer Patient Transfers

Fewer Nosocomial Infections

Reduced Nurse Turnover

Reduced Drug Cost

$2,452,800 (- 80%)

$3,893,200 (- 80%)

$80,640 (- 4/m)

$164,000 (- 14%-10%)

$1,216,666 (- 5%)

Total Cost Savings: $7,807,306


Market Share Increase

Increased Philanthropy

$2,168,100

$1,500,000

Total Revenue Gain: $3,668,100

+ Total One-Year Savings: $7,807,306

Total : $11,475,406

The Fable Hospital

Savings & Revenue (One-Year Savings)


Life-cycle vs. one-time capital costs.

The Fable Hospital

Cost avoidance savings alone, if we invested $7.8M at 3% for 30 years, it would pay the capital costs of the hospital many times over.


Once-In-A-Lifetime Opportunity

You are going to make an investment in new construction that can leave a lasting legacy to your organization and your community.It can also improve quality/safety, lower operating costs and improve

workforce morale. But to do so, ask question # 6!


Five Traditional Questions Boards & CEOs ask

1. Urgency2. Appropriateness3. Cost4. Financial impact5. Sources of funds


1. Urgency

• Is the expansion/replacement actually needed now to fulfill the mission or can it be deferred?

• For example, are the market and volume assumptions sound, and have other external factors that would affect the decision been honestly and accurately considered?


2. Appropriateness

• Is the proposed plan the most appropriate and sound?

• For example, have all alternatives been explored, such as partnerships with other hospitals and satellite operations as opposed to expanding or upgrading the facility in question?


3. Cost

• Has the project been reviewed to offer the maximum value for every dollar spent?

• Is the cost appropriate for the expected level of construction quality in light of other projects being built in the region? (The “Ford vs. Cadillac” question)


4. Financial Impact

• Has the operating impact of the additional volume been accurately analyzed financially?

• Has the operating impact of NOT proceeding also been analyzed?


5. Sources of Funds

• Have the sources of funds for the new facility been identified?

• For example, is the combination of reserves, borrowing, philanthropy, and additional operating income reasonable and defensible?


Incorporating EBD into the project canbe a superb long term investment.

The Sixth Question Boards & CEOs MUST ask

Has management incorporated allthe relevant evidencebased design (EBD), which has been shown to positively impact quality, safety, satisfaction, productivity, and operational costs?


A Continuum of Design Changes We Can Make

• Long Term – Construction• Larger/variable acuity single rooms• HEPA filtration systems• Calming views and natural light• Wider bathroom doors

• Short Term• Hand washing dispensers throughout• Reduce noise – acoustics, pagers, loud equipment • Create positive distractions through art and music• Install lifts• Improve way finding


www.healthdesign.org

More Details


--Leland R. Kaiser, Ph.D.

APPENDIX

“The hospital is a human invention and as such, can be reinvented any time.”


Contact Information

Blair L. SadlerFormer President & CEORady Children’s Hospital, San DiegoSenior Fellow, [email protected]

The Center for Health Design1850 Gateway BoulevardSuite 1083Concord, CA [email protected]

www.healthdesign.org

mailto:[email protected]

http://www.healthdesign.org


What is The Center?

• Non-profit research & advocacy organization

• Work began in 1988• Research, education, advocacy, support


Mission

To transform healthcare settings into healing environments that improve outcomes through the creative use of evidence-based design.


Vision

A future where healing environments are recognized as a vital part of therapeutic treatment; and where the design of healthcare settings contributes to health and does not add to the burden of stress.


Multi-Disciplinary

• Healthcare management• Quality improvement• Patient satisfaction• Medicine & nursing• Architecture & interior design• Research & education• Strategic planning• Capital finance


What The Center Does

• Research– Pebble Project– Special projects & reports

• Education– Conferences & programs– Certification (late 2006)


What The Center Does (cont’d)

• Advocacy– Standards– Awards programs

• Information & Support– Website– Publications– Educational consulting & speaking


Optimal Environments Value Proposition

• Strategic & business advantages• Safety & quality of care• Operational efficiency & productivity• Attract more patients• Recruit & retain staff• Increase community & philanthropic support

DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE …

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