Metrics in Healthcare Architecture

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Sacred Heart Medical Center, Anshen+Allen/Stantec, photo © Cesar Rubio

The healthcare industry is in crisis right now, and not just because of spiraling costs. Despite the Hippocratic principle to “first, do no harm,” an enormous amount of harm occurs in healthcare facilities—from misdiagnosis to medical errors to hospital-acquired infections. The growing evidence-based design movement seeks to identify and measure how the building environment can improve patient outcomes in healthcare environments.

Plenty of statistics demonstrate that being hospitalized is one of the most dangerous things that can happen to a person. According to the World Health Organization, each year 1.7 million patients in the United States pick up an infection while in the hospital, and 100,000 die. The built environment has a significant role to play in either contributing further to the problem or helping to solve it. What architects and interior designers need is credible evidence that can inform design decisions, as opposed to anecdotes or personal preference.

Sacred Heart Medical Center, Anshen+Allen/Stantec, photo ©David Wakely

Testing hypotheses
For example, Anshen+Allen (now a part of Stantec Architecture) designed a new facility, Sacred Heart Medical Center at RiverBend, for the Oregon-based nonprofit medical center PeaceHealth. PeaceHealth is a partner with the Pebble Project, the main research initiative of the Center for Health Design (CHD), a nonprofit organization formed in 1993 that works with healthcare providers to document examples of healthcare facilities whose design has made a difference in the institutions’ quality of care and financial performance. Each partner in the Pebble Project chooses which areas they are interested in evaluating. For PeaceHealth, one of the key areas of focus was reducing staff injuries.

One way to do this is to provide a patient lift in each patient room, which helps staff immensely and also reduces the risk of patient falls. These lifts are expensive to install, however, and the initial hypothesis was that given the estimated savings from reduced injuries, the return on the investment would likely be ten years. Based on that, the preliminary decision was made to incorporate patient lifts into 10 percent of the new hospital’s patient rooms.

To test the hypothesis, PeaceHealth decided to measure the potential effectiveness of the patient lifts during the design process for the new hospital. The organization converted a few patient rooms in its existing hospital in downtown Eugene into mock-ups of the ones intended for the new hospital, including patient lifts. These mockups functioned as actual patient rooms for over a year. The study found that patient lifts drastically reduced patient falls, staff injuries, missed time from work, and the need to train temporary replacement workers. According to the results of the study, the actual return on investment would be only about two to three years. And so the decision was made to install patient lifts in all of the rooms. The Center for Health Design shared the results of that study with both the design and healthcare professions, and patient lifts have since become accepted as a best practice. In a recently completed hospital, Mills Peninsula in Burlingame, we installed patient lifts in one hundred percent of the rooms. Subsequent studies showed that most injuries were caused when hospital staff were moving relatively light patients. We anticipate that this small improvement will dramatically reduce staff and patient injuries.

Integrating architectural and operational solutions
Architectural interventions alone are not enough. Of course, some evidence-based design strategies are purely architectural in nature, such as incorporating high levels of natural light. Numerous studies have shown that when patients are in an environment with views and access to daylight, their hospital stay is shorter and they have a better recovery. Natural lighting and views also improve staff satisfaction and reduce distractions, lowering the rate of medical errors.

But most evidence-based design strategies, such as patient lifts, single-patient rooms, and acuity-adaptable patient rooms, are operationally driven but architecturally implemented. An acuity-adaptable patient room, for example, allows practitioners to change the level of care around the patient, as opposed to the traditional solution of moving the patient from a critical care unit to a medical/surgical unit or a step-down unit. Every time a patient is transferred, it creates an opportunity for complications—patient or staff injuries, clinical errors, and increased possibility of infection, miscommunication, and even simple confusion over whether the patient is going to the right place. Acuity-adaptable rooms minimize the number of physical transfers for the patient, thus minimizing risk. But staff must be properly trained in order for the system to work.

Green Patient Lab, Anshen+Allen/Stantec

Navigating complexity
Healthcare projects are extremely complex, and often the challenge of implementing evidence-based design and other metrics to healthcare is that introducing any one strategy creates a variety of results, and solving one problem may create others.

Anshen+Allen has created what we call flight-ready checklists, which we implement at the very beginning of a project. The checklists allow us to identify at the outset all the best practices that we believe are important to achieve in a given project. Different practices may rise to the top, depending on the particulars of the project—for example, reducing errors, enhancing patient or staff satisfaction, and improving building performance. As we go through the process of design and are challenged by both financial and schedule restrictions, the checklist helps us hold onto those original values. It also helps resolve potential conflicts between strategies. The purpose of the checklist is not to automate the evidence-based design process, but rather to help the design team manage and retain the best practice features to assure they are not eroded during subsequent design phases. Recently, the checklists have been expanded into matrices that simultaneously track best practices for both evidence-based design and sustainable design, so a solution in one realm does not unintentionally compromise a solution in another.

Building information modeling is useful, allowing designers to simulate the performance of the building, whether that means the amount of daylight that reaches into patient rooms, the amount of heat transfer, water consumption, or distances that staff have to travel. The challenge is to put all these different criteria into the mix and understand how a change in one area may affect another.

For a project for the University of California San Francisco, we teamed with chemists at McDonough Braungart Design Chemistry (MBDC) to evaluate the long-term human health aspects of building materials by identifying known toxins used in their composition. To investigate materials is time-consuming and challenging, especially since the research isn’t always in agreement and manufacturers don’t always fully disclose the contents of their products. We started with the patient room and exam room, considering materials commonly used on different surfaces: walls, floors, and ceilings. We then prioritized the surfaces according to which ones have the most impact on occupants—for example, people are more likely to come into contact with the walls than the ceiling. The results of the study influenced which finishes and products we chose, not just in the patient and exam rooms, but throughout the facility.

Yet measuring the impact of materials on environmental health is equally crucial. Unfortunately, some products perform well in one area and very poorly in the other. For example, paints with antimicrobial additives are highly toxic to the environment. Realizing this led us eliminate the use of these materials and to focus on other strategies for preventing the spread of infection.

Given rising healthcare costs, we are in a time of acute financial scrutiny. Major decisions are made on the basis of cost. Almost every institution is looking for ways to reduce square footage to save money. Balancing the cost implications of architectural and operational decisions is necessary—and not always intuitive. It took many years for the Facilities Guidelines Institute, which establishes minimum standards for healthcare planning throughout the United States, to change its guidelines to recommend that hospitals switch to all single-patient rooms. There was a perception that the switch would cost more, because if every room is private, that requires more square footage. Even with strong evidence that private patient rooms significantly reduce the spread of infection, reduce medical errors, eliminate the need for patient transfers related to roommate incompatibility, and increase patients’ willingness to share their medical history, it took a long time for this approach to gain widespread acceptance. Initially, it seemed obvious that one of the metrics should be square footage. But if single-patient rooms enable better bedside care, more point of care procedures, better clinical outcomes, shorter lengths of stay, and less turnover, then minimizing room sizes might actually be the more expensive solution. Right-sizing rooms, as opposed to downsizing them, could easily become not only clinically but also financially beneficial.

The future is in knowledge sharing
There are a growing number of organizations and resources for metrics related to the intersection of healthcare and design. The Healthy Building Network’s Pharos Project provides health and environmental data about the manufacture, use, and end of life of common building materials. The Health Environments Research and Design Journal is the first interdisciplinary, peer-reviewed journal to focus on healthcare environment research. Kaiser Permanente has also partnered with the Center for Health Design to create the Ripple Database, an open-source, searchable, web-based database of Kaiser’s best practice design strategies related to patient safety, worker/workplace safety, and environmental safety. In addition to the Center for Healthcare Design, other organizations engaged in research into metrics include The CARITAS Project, the Center for Medicare and Medicaid Services, the Institute for Healthcare Improvement, Health Care Without Harm, and the Robert Wood Johnson Foundation.

Healthcare institutes historically have not shared statistics about medical errors in their facilities, and design firms have traditionally been protective of intellectual property. But the healthcare crisis is serious, and attitudes are changing. There’s a growing trend toward sharing information, as designers and institutions recognize that those that share knowledge are often perceived as leaders in this collaboration.

Green Patient Lab headwall, Anshen+Allen/Stantec;
right, Sacred Heart Medical Center, Anshen+Allen/Stantec, photo ©David Wakely


Bill Rostenberg

Bill Rostenberg, FAIA, FACHA, ACHE, EDAC, has written numerous books and articles about the design and planning of healthcare facilities, including "The Architecture of Medical Imaging" and The Society for Imaging Informatics in Medicine (SIIM) PACS Handbook chapter on Reading Room Design. He is an Advisory Board Member of the Health Environments Research and Design Journal and is a guest instructor at Harvard University Graduate School of Design, Clemson University Graduate program in Architecture + Health, The Radiological Society of North America, The American College of Healthcare Executives, and numerous other medical and architectural professional organizations. In 2010, Bill was recognized by Health Design Magazine as "The Most Influential Person in Health Facility Design," and he has been honored with AIA national and local presidential citations for Extraordinary Service to the Profession.

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