CASE 25:An Evidence-Based Design for Waterford HospitalAnn Scheck McAlearney and Nathan BurtCampeon Health is a Midwestern healthcare system comprising five hospitals, ten affiliated hospitals, and an extensive ambulatory care network. Given favorable demographics and a strong bottom line, Campeon Health has recently decided to construct a new hospital in Waterford, a suburb of the larger Grouse Creek metropolitan area. In all, Grouse Creek currently contains three major hospital systems and a children’s hospital, but despite steady population growth, new hospitals have been scarce. The Campeon Health facility would be the region’s first newly constructed hospital in more than 22 years. Planned to be a 90-bed community hospital, Waterford Hospital could serve as a feeder hospital for the system’s large flagship hospital, Lakeside Hospital, while accommodating the preferences of physicians interested in expanding their practices to include the Waterford community.The ChargePrior to breaking ground for the new facility, Campeon Health has named Katherine Humphries, RN, as president of Waterford Hospital. Humphries had worked as CEO of another Campeon Health hospital for three years, and she has established a strong reputation as a transformational leader. She has been charged by the board of Campeon Health and the Campeon Health CEO to lead the initiative to design, construct, staff, and operate the new community hospital in Waterford. At the present time, the Waterford Hospital site is nothing more than a field, located across the street from an existing Campeon Health ambulatory care center.Humphries has been given relatively free rein to design the hospital. Her years of experience as a registered nurse and as an operations leader have given her valuable insights into the delivery of care and the ways that it can be improved. She is aware that elements of evidence-based design have been shown to improve care quality for patients and workplace climate for caregivers, and she is eager to consider this approach.Evidence-Based DesignEvidence-based design is increasingly being used by hospitals that are trying to improve staff morale, patients’ experiences, and the outcomes of care provided. Such designs are specifically used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance, and restorative for workers under stress. Ultimately, evidence-based healthcare designs should result in demonstrated improvements in the organization’s clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures. However, this healthcare design approach is a relatively new concept. The pool of available research and information will rarely fit a hospital’s situation precisely, thus requiring critical consideration of specific design modifications and project goals.Evidence-based design is particularly appropriate for healthcare. Physicians are accustomed to practicing, at least in part, according to evidence-based clinical guidelines and measures, while managers are increasingly using evidence-based management principles (Kovner and D’Aunno 2017). Thus, the notion of applying evidence to the task of hospital design may be well received. Further, some design principles focus on the physical characteristics that can reduce stress and contribute to the healing process, which could be especially important for patients and families dealing with the stressful and often frightening experiences common to hospital stays. Hospitals themselves have been shown to benefit—both in terms of reduced costs and increased organizational effectiveness—when applying the principles of evidence-based design (Saba and Hamilton 2006).Evidence-based design principles incorporate a variety of elements and have in many cases been demonstrated to be effective. Design elements that have shown particular promise include exposure to sunlight, access to nature (either direct access or views), acuity-adaptable rooms, and decentralized nurse stations. Some studies have shown that climate and exposure to sunlight can influence the length of a patient’s stay. One research group randomly assigned bipolar patients to sunny rooms and to rooms with less exposure to sunlight. The mean length of stay for patients exposed to greater amounts of sunlight was 3.67 days shorter than that for the control group. Similarly, patients recovering from abdominal surgery were found to have shorter hospital stays if they had a bedside window view of nature rather than windows that looked out onto a brick wall (Ulrich et al. 2004).Well-designed rooms and buildings can bring about improved clinical outcomes in a variety of ways. An action as simple as placing an alcoholic hand-rub dispenser at the patient’s bedside can yield significant improvements in practitioners’ handwashing practices, thereby reducing contact infection rates. Efforts to address poor lighting, environmental distractions, and workflow interruptions can help prevent medication administration errors. Well-designed rooms can reduce the likelihood of patient falls, and good building design can reduce noise levels, thereby reducing stress for patients and caregivers (Ulrich et al. 2004).A Growing Evidence BaseHumphries was aware that improvements in clinical and patient satisfaction outcomes associated with the introduction of acuity-adaptable rooms were starting to become documented. In particular, she was intrigued by two examples from the recent research literature—one from Clarian Health in Indianapolis, Indiana, and one from Celebration Health in Orlando, Florida.Example: Clarian HealthClarian Health switched from a traditional model of care to an acuity-adaptable model in coronary care by building an acuity-adaptable comprehensive critical coronary care floor (CCCC). The acuity-adaptable CCCC is capable of performing all necessary care in one room, from admission to discharge (Brown and Gallant 2006). Using a pre–post design to evaluate the success of the model, Clarian recorded two years of baseline data prior to CCCC adoption and then compared clinical outcomes after CCCC adoption against that baseline data.During the baseline period, the two units that were to become the CCCC had an average of 200 intraunit transfers per month. The time spent coordinating transfers, processing paperwork, and transporting patients was considered to be non-value-added and would be better spent in direct patient care. In addition, these 200 handoffs per month elevated the risk of medical errors associated with the handoffs. After moving to an acuity-adaptable model of care, intraunit transfers were cut by 90 percent (Hendrich, Fay, and Sorrells 2004). Also noteworthy, medication errors were cut by 70 percent, likely due at least partially to the reduction in patient handoffs and transfers. Finally, patient falls decreased to a national benchmark level, and patient satisfaction increased overall (Hendrich, Fay, and Sorrells 2004).Example: Celebration HealthCelebration Health implemented an acuity-adaptable model within its new facility and saw marked improvements in clinical outcomes. In particular, patients’ lengths of stay for most diagnosis-related groups (DRGs) declined significantly after the introduction of the acuity-adaptable model. Comparing data with another state, Celebration Health reported that the average length of stay for five specific DRGs in its system was 5.4 days, compared with 9.5 days reported in the state of California. Within those five DRGs, 30 percent of Celebration Health patients were discharged within four days. These length-of-stay improvements occurred with simultaneous reductions in nursing hours per patient day (Gallant and Lanning 2001).Financial ImplicationsConstruction costs per square foot for an evidence-based design building are not much higher than for a traditional building, but increased costs should be anticipated. For instance, overall construction costs may be higher because of the architectural modifications necessary to introduce sunlight within 95 percent of the building or because of the greater square footage required for innovations such as acuity-adaptable rooms. From a design standpoint, introducing sunlight for internal spaces can be tricky. One solution might be to build gardens within the core spaces of a building. Though such gardens tend to be expensive, they offer visible areas for community support and can contribute to a healing environment. Acuity-adaptable rooms must be able to accommodate a large range of equipment and have space for family members; as a result, they may have to be 30 to 50 percent larger than traditional single-occupancy rooms.At the same time, evidence-based design can reduce costs associated with utilities. The availability of sunlight throughout the building, for instance, will reduce electricity costs. Similarly, maintenance and supplies costs are typically reduced because of standardized equipment and supplies throughout the hospital.Capitalizing on the OpportunityHumphries is convinced that an evidence-based design model will be appropriate for Waterford Hospital. Working with the hospital architect and contractor, she has been able to outline an evidence-based design that includes such components as acuity-adaptable patient rooms, decentralized nurse units, and liberal use of windows and open spaces to provide patients and families with access to nature. The latest architectural drawings feature all private rooms for patients, each room including a family area designed to contain a couch/bed, refrigerator, and separate television. In addition, gardens both inside and outside the hospital will have easy access points for patients, families, and hospital staff. Staff and families will also have access to respite areas, where they can go to relieve stress and deal with difficult situations and decisions. Finally, all patient areas, and 95 percent of other hospital space, are designed to have access to direct or indirect sunlight.Overall, Humphries is pleased with the preliminary plans for Waterford Hospital. However, she knows she has a long way to go to convince hospital staff and physicians—who are generally accustomed to traditional hospital environments—that the evidence-based design model is sound and desirable. In fact, moving forward with an evidence-based design is risky if she does not get key stakeholders on board. Humphries knows her next step is to build support for the application of an evidence-based design for Waterford Hospital, but she doesn’t have much time.
Case QuestionsWho are the key stakeholders who must support Humphries’s vision for an evidence-based hospital design? How could she obtain their support?What reactions might you predict from physicians regarding the use of evidence-based design at Waterford Hospital? How about from members of the Waterford community? Other local hospitals and health systems?What challenges do you think Humphries and the leadership team at Waterford Hospital will face as they try to implement an acuity-adaptable model of care?ReferencesBrown, K. K., and D. Gallant. 2006. “Impacting Patient Outcomes Through Design: Acuity Adaptable Care/Universal Room Design.” Critical Care Nursing Quarterly 29 (4): 326–41.Gallant, D., and K. Lanning. 2001. “Streamlining Patient Care Processes Through Flexible Room and Equipment Design.” Critical Care Nursing Quarterly 24 (3): 59–76.Hendrich, A. L., J. Fay, and A. K. Sorrells. 2004. “Effects of Acuity-Adaptable Rooms on Flow of Patients and Delivery of Care.” American Journal of Critical Care 13 (1): 35–45.Kovner, A. R., and T. D’Aunno (eds.). 2017. Evidence-Based Management in Healthcare: Principles, Cases, and Perspectives, 2nd ed. Chicago: Health Administration Press.Saba, J., and K. Hamilton. 2006. “The Bottom Line on Evidence-Based Design.” Presentation at the American College of Healthcare Executives Congress on Healthcare Leadership, Chicago.Ulrich, R., X. Quan, C. Zimring, A. Joseph, and R. Choudhary. 2004. Unpublished paper presented at virtual seminar on healing environments, American Institute of Architects, Academy of Architecture for Health.
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