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Overwhelming Evidence
Study shows direct link between patient
health, quality of care, hospital design
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The hospital industry is in the throes of a major building boom: In the next decade, an estimated $200 billion will be spent on new hospital construction across the United States. At the same time, a new analysis of more than 400 research studies by The Center for Health Design shows a direct link between patient health and quality of care and the way a hospital is designed. Here are a few examples:
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Patient falls declined by 75 percent in the Cardiac Critical Care Unit at Methodist Hospital in Indianapolis, Ind., which made better use of nursing staff by spreading out their stations and placing them near patients' rooms.
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The rate of hospital-acquired infections decreased 11 percent in new patient pavilions at Bronson Methodist Hospital in Kalamazoo, Mich., that feature private rooms and specially located sinks.
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Medical errors fell 30 percent on two new inpatient units at The Barbara Ann Karmanos Cancer Institute in Detroit that allocated more space for their medication rooms, re-organized medical supplies, and installed acoustical panels to decrease noise levels.
The evidence is overwhelming: The healthcare environment — where care is actually provided and received — has substantial effects on patient health and safety, care efficiency, and staff effectiveness and morale.
"We are faced with the unprecedented opportunity — and challenge — to use what we know to design better, more effective hospitals," says Roger Ulrich, Ph.D., of Texas A&M University.
Ulrich and Craig Zimring, Ph.D., of Georgia Tech University, conducted the research analysis for The Center for Health Design - the most extensive review ever done of the evidence-based approach to hospital design. With their findings, we now know enough about the "science" of hospital design to ensure that future hospitals can be much more geared to promoting healing, not just providing treatment. They can also be satisfying places to work, not ones in which new nursing graduates stay only a year or two. And their improved design, work processes, and culture can increase institutional vitality and improve the bottom line.
"Just as evidence-based medicine is revolutionizing health care treatment, evidence-based design is transforming the healthcare environment," Zimring says. "We now have at our disposal proven architectural methods for improving patient outcomes, safety, and satisfaction, as well as staff retention and service efficiency."
America's Hospitals Are Falling Short
The U.S. spends approximately 14 percent of its Gross National Product on healthcare, much of which is provided in hospitals. Yet, despite this enormous expenditure and the technological resources available, hospital care today frequently runs afoul of the cardinal rule of medicine: First, do no harm.
As the landmark 2000 Institute of Medicine report To Err is Human revealed, hospitals regularly fall far short of ensuring patient safety. As many as 98,000 Americans die each year because of preventable medical errors while in the hospital. In fact, more people die in a given year from hospital errors than from motor vehicle accidents, breast cancer, or AIDS.
In addition, up to 2 million U.S. hospital patients — 1 in 20 of all those admitted — contract dangerous infections every year during their hospital stays. In 1995, hospital-acquired infections — or nosocomial infections, as they're also called — cost $4.5 billion and contributed to more than 88,000 deaths. They are a leading cause of death in this country.
Hospitals also create stress for patients, their families, and staff alike. Negative effects of stress include:
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Anxiety, depression, and anger (psychological);
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Increased blood pressure, elevated levels of stress hormones, reduced immune function (physiological); and
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Sleeplessness, aggressive outbursts, patient refusal to follow doctor's instructions, staff inattention to detail, and drug or alcohol abuse (behavioral).
The design of the hospital environment contributes to all these problems. Poor air quality and ventilation, together with two or more patients in the same room, are major causes of nosocomial infection. Inadequate lighting is linked to patient depression as well as to staff's medication errors. Lack of a strong nursing presence can result in patient falls. Staff members often have to do their charting and fill medication orders in crowded, busy makeshift areas, which can lead to errors and increase staff burnout.
Hospitals produce stress in a variety of ways. Excessive noise from paging systems, alarms, machines, and voices upset patients and distract staff. Poorly designed hospitals where people can get lost easily or that force bedridden patients to stare directly at glaring ceiling lights can cause anxiety and a sense of helplessness. Double-occupancy rooms that impinge on patients' right to privacy and rest can impede their recovery. There are few places where patients can talk quietly with their families or with staff.
In order to create a model healthcare environment for the 21st century, hospitals need to be improved on several levels: their physical design and construction; the ways in which staff do their work; and their institutional culture. Ulrich's and Zimring's work speaks to this first issue.
Putting the Evidence into Action
Evidence-based design can improve hospital environments in three key ways by:
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Enhancing patient safety by reducing infection, risk, injuries from falls, and medical errors.
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Eliminating environmental stressors, such as noise, that negatively affect outcomes and staff performance.
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Reducing stress and promote healing by making hospitals more pleasant, comfortable, and supportive for patients and staff alike.
Based on their review of the evidence, Ulrich and Zimring make the following recommendations:
Get rid of double-occupancy rooms and provide patients with single rooms that can be adjusted to meet their medical needs as they change during their stays. This change alone will help improve patient safety by reducing patient transfers, cut the risk of nosocomial infections, enhance patient privacy, lower stress for patients and their families, and improve staff communication with patients. Although the up-front cost of private rooms is higher, significant savings will accrue from lower rates of infection, readmission, and transfers, as well as shorter hospital stays.
Improve indoor air quality with well-designed ventilation systems and air filters to prevent nosocomial infection. Several studies have demonstrated that identifying and fixing air-quality problems, in combination with single rooms and scrupulous hand-washing, can substantially lower infection rates at hospitals. Maintaining good air quality involves careful design, location, and control of environmental elements.
Use sound-absorbing ceiling tiles and carpeting to reduce noise — which will lower stress for patients and staff alike. Research shows that noise is a major source of stress at hospitals. At hospitals that took steps to cut noise levels, patients were more satisfied with their care, slept better, had lower blood pressure, and were less likely to be re-hospitalized. Likewise, staff felt better about their jobs and reported improved sleep quality.
Provide better lighting and access to natural light to reduce stress and improve patient safety. Looking out at bright light can improve health outcomes, including depression, agitation, sleep, and circadian rest-activity rhythms. In one study, hospitalized patients with unipolar and bipolar disorder whose rooms received direct sunlight in the morning had significantly shorter hospital stays than patients whose rooms did not. Poor lighting also contributes to medication errors.
Create pleasant, comfortable, and informative environments to relieve stress and promote satisfaction among patients, their families, and staff. Small changes to room layouts, color scheme, furniture choice and arrangement, floor coverings, and curtains, as well as providing informational material and displays, can improve people's moods and physiological states. Several studies have shown that views of nature and gardens can effectively reduce stress and alleviate pain through pleasant distraction. Outdoor gardens with seating also create enjoyable and soothing visiting environments for patients and their families. One study found that children hospitalized for psychiatric problems became much less aggressive when they were placed in an "improved" quiet room with pleasant decor, compared to those who were placed in a standard quiet room. "Rooming-in" accommodations for family members increase social support and help relieve stress for patients.
Make hospitals easier — and less stressful — for patients and their families to navigate. It's easy to get lost or confused trying to find one's way in a hospital. Not only is this confusion stressful for visitors, but it also incurs a cost to hospital. One study of a major tertiary care hospital calculated the annual cost of "wayfinding" at $220,000 — mainly due to the time spent direction-giving (more than 4,500 staff hours) by people other than information staff. Good wayfinding systems include mail-out maps and written directions, you-are-here maps and directories and key entries, directional signage at key decision points, reassurance signs for long paths, and clear identification of rooms.
Design hospitals that help staff do their jobs. Nursing stations are hectic and stressful places where too many errors occur while updating charts, filling medication orders, and communicating between shifts. Several studies have found that providing orderly, well-lit spaces that are organized around critical activities by nurses and physicians can reduce medication errors and reduce staff stress.
These types of changes can produce very real — and very positive — effects. Bronson Methodist Hospital used an evidence-based approach in the $181 million redevelopment of its hospital campus in downtown Kalamazoo. Evidence-based design features include private rooms with rooming-in accommodations for all patients; creative use of artwork, music, light, and nature to create a more pleasant and less stressful environment; shorter walking distances for patients and families with seating along the way; and touch-screen information kiosks at every main entrance. Among the results:
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11 percent reduction in nosocomial infections
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Nursing turnover rates below seven percent (the national average is 20)
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95.7 percent overall patient satisfaction
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Improved staff satisfaction
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Increase in market share
Leonard Berry, Ph.D., of Texas A&M University, says that evidence-based design is not only good healthcare; it's good business sense as well. "Smarter hospital architecture and design can pay for itself within a year by improving service efficiency, patient safety and satisfaction, and market share," Berry says.
For more information, visit the website of The Center for Health Design at www.healthdesign.org. The Center for Health Design is a nonprofit research and advocacy organization based in Concord, CA. Its mission is to transform healthcare settings into healing environments that improve outcomes through the creative use of evidence-based design.
This work is supported by The Robert Wood Johnson Foundation, the nation's largest philanthropy devoted exclusively to health and healthcare.
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