In 1999, the Institute of Medicine shocked the health-care industry with its landmark report, "To Err Is Human," which highlighted the staggering human and financial costs of medical error: an estimated 44,000 to 98,000 in the U.S. dead each year as a result of medical errors, more than from motor vehicle accidents or breast cancer, costing the country between $17 billion and $29 billion in health-care costs, disability, and lost income.
Yet it wasn't all fire and brimstone. The report emphasized the benefit to be had from focusing not on individual people making individual mistakes, but rather on the systems themselves. Health care, the Institute of Medicine said, had to learn from industries such as aviation, nuclear power, and construction that dramatically increased safety using "systems thinking," looking holistically at failures, rather than identifying a single weak link.
For health care, that meant replacing individual blame with collective responsibility. Improvements are already visible. In June, Dr. Donald Berwick of the Harvard School of Public Health announced that an estimated 122,300 lives had been saved in just the last 18 months, as a result of changes—ranging from improved hand-washing to establishing an organization-wide mandate for safety—recommended by the "100,000 Lives Campaign" sponsored by the Institute for Healthcare Improvement, a Cambridge (Mass.)-based nonprofit.
DESIGN FOR LIFE.
But there is plenty more to be done and one of the most promising areas to focus on is design. "Hospitals are dangerous places because of systems, and systems are a design problem," explains Derek Parker, co-founder of the Center for Health Design, a nonprofit think-tank, and a director in San Francisco at Anshen + Allen Architects, a leading health-care design firm.
For Parker, the solution starts with the building. "We're expanding the definition of architecture. It isn't about choosing fabrics for the lobby," Parker adds.
Forget fancy entrances, healing gardens, and feng shui—more aesthetic elements of building design whose impact on patient health is easy to suppose but difficult to prove. Over the past seven years, hospital architects have increasingly awakened to the possibilities for design to save lives. To do that, they are taking a page from medicine's playbook.
Just as doctors are increasingly turning to "evidence-based medicine," which uses research data, rather than expert opinion, as a tool to make clinical decisions, so architects are linking statistical evidence—on patient outcomes, staff turnover, etc.—to the physical environment. Such "evidence-based design" is driving a range of innovations.
Yet in health care, large-scale innovation is easier said than done. "Most people building a hospital have never done it before, and will never do it again," says architect Parker. "They're spending several hundred million dollars of their community's money and they're scared." So the evidence not only informs design decisions, it helps convince building clients and communities to accept them.
And not a moment too soon: The aging baby-boomer population is expected to drive annual spending on hospital construction past $30 billion by 2009, up from $19.8 billion last year, according to FMI, a construction research firm. For the evidence-based design movement, that boom means a unique opportunity to have a major effect on the next generation of hospitals.
But given the financial strain hospitals are under—a recent McKinsey & Company report showed that, between 1990 and 2004, health-care facilities' compound annual growth rate was 5.1%, while pharmaceuticals and insurance grew 8.9% and 11.3%, respectively—there's little appetite to invest in untested ideas. Ample data is crucial to implement innovation.
In a research report funded by the Robert Wood Johnson Foundation, the Center for Health Design identified more than 600 articles in peer-reviewed scientific journals demonstrating the effects of the hospital environment on patient health and safety, care efficiency, and staff effectiveness and morale.
The report opened the door for design improvements, many of which are now being deployed in "Pebble Projects," a research program run by the Center for Health Design to help hospitals compare design innovations with pre-existing conditions. The goal is for the nearly three dozen hospitals currently participating to be "pebbles" that create ripples through the entire health-care industry.
WRONG SIDE SURGERY.
The opportunities for using design to improve hospitals range from the subtle to the mundane, the environmental to the ergonomic. Increasing natural light and reducing noise, for instance, lower stress levels for both patients and staff (see BusinessWeek.com, 08/15/06, "Seeing the Light").
Standardizing operating rooms within a hospital minimizes the likelihood of wrong-site, wrong-side, or wrong-patient surgery (a not uncommon occurrence). Arranging nursing stations to improve access to both patients and charts reduces errors and fatigue. And perhaps most important, providing private rooms improves infection control, allows families to help with care, and minimizes environmental stressors such as noise and light.
Many of these changes have an impact on more traditional management and financial metrics as well. For example, at the newly constructed 210-bed Parrish Medical Center in Titusville, Fla., surveys revealed that a majority of hospital workers thought the new design improved their ability to deliver care. In the first year after the building's completion, staff turnover dropped from 14.1% to 12.5%.
A Pebble Project at the $181 million Bronson Methodist Hospital in Kalamazoo, Mich., is comparing the old and new facilities in terms of employee turnover, patient outcomes, patient length of stay, health-care costs, cost per unit of health-care service, patient waiting time and satisfaction levels, hospital-acquired ("nosocomial") infection rates, and a culture that promotes safer care.
Most significantly, nosocomial infection rates decreased by 11% since the opening of the building—thanks to the use of private rooms, the installation of more sinks to encourage frequent hand-washing, and a new ventilation system design. Evidence of the benefits of private rooms has proved so overwhelming, in fact, that last month the American Institute of Architects changed its guidelines for hospital design to mandate them in all new hospital construction.
Of all of the Pebble Project sites, Bronson Methodist is perhaps the closest there is to the Center for Health Design's "Fable Hospital," an imagined facility encompassing all known improvements based on the pebble research. Conceived as a 300-bed urban hospital built for $240 million, Fable has all private, "acuity-adaptable" patient rooms—meaning they can accommodate a variety of conditions, reducing the need for room changes which provoke errors and extend recovery times.
PAYS FOR ITSELF.
The Center for Health Design estimates that, all told, these and Fable's other features would add $12 million to the hospital's construction costs. But thanks to reduced patient falls, transfers, nosocomial infections, nurse turnover, and drug costs, as well as increased market share and philanthropy, the Center believes those costs would be recouped within a year.
"There's a limited pot of money out there to build and operate these facilities," explains architect Robin Guenther, whose New York-based Guenther 5 Architects has a national reputation for innovative medical facilities. "And if it's going to cost more to build it better cost less to operate."
Adds the Center for Health Design's Parker, "It costs a lot of money to build a poor hospital, and only a little more to build a better hospital."
PUSH TO GREEN.
It's a message Kaiser Permanente—the nation's largest HMO, with eight million patients and 63 million square feet of space—is taking seriously. Kaiser's massive scale puts it in a unique position to embrace evidence-based design. By mining its built-in treasure trove of patient information, Kaiser's national facilities team can correlate patient outcomes with hospital design—exploring the impact on patient outcomes of everything from the cardinal direction a patient room faces to the type of flooring.
"We're trying to take accountability for evidence-based design and see what we can do to push it," says John Kouletsis, Kaiser Permanente's director of Strategy, Planning, and Design in its National Facilities Services office.
One of the directions the evidence is pushing Kaiser is towards green design. Just as businesses are finding green design increases productivity, there is data showing that sustainable design allows hospitals to improve care while keeping down costs. At best, sustainable design increases natural light and views, improves indoor air quality, and reduces toxic chemicals in hospitals—a crucial issue in an industry dependent on powerful disinfectants and with staggeringly high rates of adult-onset asthma among staff.
For Kaiser, green design includes both resource-saving measures such as green roofs and permeable paving, as well as solutions that improve patient outcomes. For example, Kaiser has changed its network-wide flooring standard to eliminate PVC-based vinyl flooring, reducing the pollution created on disposal, while reducing slips, trips, and falls, lowering noise levels, and creating a more comfortable work environment for staff.
"We would never pursue green just for the sake of green," explains Kouletsis. "It will always be high on our agenda to do no harm to the communities in which we operate, but we also consider if it provides for patient safety, for better patient outcomes, and for staff and physician safety."
Green materials are just one element of Kaiser's Sidney R. Garfield Center for Healthcare Innovation, a 35,000-square-foot space near the Oakland airport used to mock up a variety of care environments, in order to test new technologies and design strategies.
Opened in June, the research center will provide the evidence to guide Kaiser as it embarks on a $24 billion, 10-year capital building campaign, for both new construction and seismic retrofit in accordance with California's Hospital Seismic Safety Act. Known as SB 1953, the legislation requires that all acute care hospitals be seismically upgraded by 2013—a move expected to cost at least $41.7 billion, according to a 2002 RAND report, which is currently being revised.
Yet for all of these projects, the challenge remains bringing design deeper into the process of delivering care. As Dr. Paul Schyve of the Joint Commission on Accreditation of Healthcare Organization explains, "When people use the phrase 'evidence-based medicine' they're thinking about specific things you do in clinical care.
But I would be inclined toward a broader concept of evidence-based health-care: How does the team as a whole come together and how does it interact with its environment? Evidence-based design is a component of evidence-based health-care because the design is part of the systems and processes and those are what cause errors."