Why Building Better Hospitals Will Reduce Harm, Increase Joy in Work, and Save Money

1. Why Building Better Hospitals Will Reduce Harm, Increase Joy in Work, and Save Money Blair L. Sadler, JD Former President & CEO Rady Children’s Hospital, San Diego, CA Senior Fellow, Institute for Healthcare Improvement Vice Chair, Center for Health Design

5. 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.

6. 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

7. Facts • The patient safety problem is large. • It (usually) isn’t the fault of healthcare workers. • Most patient injuries are due to system failures. Institute for Healthcare Improvement, 2001

8. 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 die Modern Healthcare, 2006 Nursing turnover: 20% per year JCAHO, 2002

9. Healthcare Workers 75%believe 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. Connecticut Nurses’ Association

10. Components of Quality PATIENT CENTERED TIMELY EFFICIENT QUALITY EFFECTIVE EQUITABLE SAFE

11. Components of Quality SOUND WAYFINDING ACCESS TO NATURE SCALE AROMA FURNISHINGS QUALITY LIGHT MATERIALS COLOR PRIVACY/CONTROL TEXTURE SAFETY & SECURITY ART

12. Making a Key Connection Most healthcare environments are more stressful and riskier for patients, family members, and staff than they should be. They actually make these problems worse! Conversely, improved design can measurably improve care and the work environment.

13. Six Domains of Quality Aims Promises Results Safe Effective Efficient Patient Centered Timely Equitable Patient People Processes Information Microsystems IT Human Resources Finance Leadership Organization Funding Community Government Environment Levels of Transformational Change

14. Big Issues in the Next Ten Years of Improvement • The interactions between patients and the system of care • The organization context of care • The environmental context of care Donald M. Berwick, MD, MPP Institute for Healthcare Improvement 1st Annual Forum for Improving Children’s Health Care March 12, 2002

15. “In service industries, the environment is the most objective and visible sign of respect for the patient, family and staff.” Leonard L. BerryAuthor, Discovering The Soul of Service

16. “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 MartinThe LancetAugust 2000

17. Healthcare Building Boom • Aging facilities • Aging population • Bed shortages and capacity bottlenecks Construction Cost Estimates: $35 billion by 2009 Source: FMI

18. Evidence-Based Design Research

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

20. EBD ResearchLiterature Search - 1998 • Johns Hopkins University • Rubin and Golden meta-analysis • 84 studies • Published report

21. EBD ResearchLiterature Search - 2004 • Robert Wood Johnson Foundation • Texas A&M, Georgia Tech • Ulrich and Zimring meta-analysis • 600+ studies • Published report, abstracts

22. EBD ResearchLiterature Search - 2004 Rigorous studies link the environment to outcomes in four areas: • Reduce patient stress • Reduce staff stress • Improve safety • Improve quality

23. Reduce stress, improve quality of life and healing for patients and families Reduce noise stress Reduce spatial disorientation Improve sleep Increase social support Reduce depression Improve circadian rhythms Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients & families Provide positive distraction Patient stress (emotional duress, anxiety, depression) EBD ResearchPatient StressScorecard Ulrich & Zimring, 2004

24. 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 ResearchStaff StressScorecard Ulrich & Zimring, 2004

25. 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 ResearchPatient SafetyScorecard Ulrich & Zimring, 2004

26. Improve overall healthcare quality and reduce cost Reduce length of patient stay Reduce drugs (see patient safety) Patient room transfers: number and costs Re-hospitalization or readmission rates Staff work effectiveness; patient care time per shift Patient satisfaction with quality of care Patient satisfaction with staff quality EBD ResearchQualityScorecard Ulrich & Zimring, 2004

27. 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.

28. Research ConclusionsImmediate action • Provide larger single-bed rooms • Provide variable acuity rooms/reduce transfers • Reduce noise to reduce stress and 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 and fatigue • Provide equipment to reduce staff injuries • Install visible/accessible hand washing facilities

29. What is The Center? • Non-profit research and advocacy organization • Work began in 1988 • Research, education, advocacy, support

30. The Pebble Project®

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

32. The Pebble Pioneers - IMPACT • 40 active provider partners • 4 corporate partners • 2 alumni • Various project types • Different stages of design

33. Pebble Project Benefits • Research methodology • Research facilitation • Marketing opportunities • Learning workshops • Consulting and technical expertise • Recognition • Community

34. Bronson MethodistKalamazoo, MI • $181 million • December 2000 • $42 million less for new construction Architecture & Interior Design: Shepley Bulfinch Richardson & Abbott

35. Bronson MethodistDesign Features • Access to nature • Control • Positive distractions

36. Bronson MethodistAreas of Measurement • Turnover • Outcomes • Length of stay • Cost per unit of service • Waiting times • Satisfaction • Organizational behavior • Productivity

37. Bronson MethodistSelected Data: Safety & Operations • 11% decrease in infections • $500,000 savings a year in transfers • Increased market share • 87% occupancy

38. Bronson MethodistSelected Data: Consumer Preferences

39. Bronson MethodistSelected Data: Satisfaction • 5.4% nurse turnover • Increased employee satisfaction • 96.7% patient satisfaction

40. Bronson MethodistSelected Data: RN Turnover Source for National Benchmark: The Advisory Board Source for Best Practices: ANCC

41. Bronson MethodistSelected Data: Overall Turnover

42. Bronson MethodistSelected Data: Patient Satisfaction

43. Bronson MethodistPerformance Results

44. Bronson MethodistPerformance Results

45. 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.

46. 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).

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

48. 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

49. EBD Design Features • Oversized, windowed, single rooms • Variable acuity rooms • Decentralized, barrier-free nursing stations • Additional hand-washing facilities • HEPA filters • Ceiling lifts

50. Methodist HospitalIndianapolis, IN Architecture & Interior Design:BSA LifeStructures