Evidence-based design could help quality of care

Literature review shows impact on outcomes

You may not be an architect, but it might be time for you to start paying a little more attention to the way your hospital is designed — especially if you’re about to have a new facility built or you’re embarking on a substantial renovation.

That’s the message coming from the Concord, CA-based Center for Health Design (www.healthdesign.org), which recently commissioned an analysis of more than 600 research studies. The analysis shows a direct link between patient health and quality of care and the way a hospital is designed.

The review, conducted by Craig Zimring, PhD, professor of architecture and an environmental psychologist at the Georgia Institute of Technology in Atlanta, and Roger Ulrich, PhD, director of the Center for Health System and Design at Texas A&M University in College Station, outlines the benefits of an evidence-based approach to hospital design.

"Just as evidence-based medicine is revolutionizing health care treatment, evidence-based design is transforming the health care environment," says Zimring. "We now have at our disposal proven architectural methods for improving patient outcomes, safety, and satisfaction, as well as staff retention and service efficiency."

According to his report, evidence-based design can:

  • enhance patient safety by reducing infection, risk, injuries from falls, and medical errors;
  • eliminate environmental stressors, such as noise, that negatively affect outcomes and staff performance;
  • reduce stress and promote healing by making hospitals more pleasant, comfortable, and supportive for patients and staff alike.

Reducing stress

It’s important to note that evidence-based design can reduce stress, not only for patients and families, but for staff as well, Zimring explains.

"I think hospitals are very risky and stressful places for the people who work in them, but also for patients and families," he says.

"We know that according to the Institute of Medicine (IOM), between 44,000 and 88,000 people die each year due to preventable errors, which is more than the number of people who die of breast cancer, automobile accidents, or AIDS.

Likewise, an estimated 88,000 die due to nosocomial infections. We also know that the IOM and the IHI [the Boston-based Institute for Healthcare Improvement] argue that one of strongest measures we can take to boost safety is to hire more nurses," Zimring notes.

At the same time, he points out, the United States is starting one of the largest hospital building booms in history.

"It’s a perfect storm — aging baby boomers, people moving to the Sunbelt, and replacing all the hospitals built in the 60s and 70s," Zimring explains.

"The prediction is that in this year there will be between $16 billion and $27 billion worth of hospitals built," he adds.

The good news, Zimring says, is that "there is a body of scientifically defensible evidence that says the physical environment can affect patient safety, stress, the ability of staff to do a good job, staff stress, and nursing turnover."

For example, the national average for nursing turnover is 20% a year, he explains. "But some facilities, like the Mayo Clinic, have 3% to 4% a year. "What’s clear is that the environment impacts outcomes — it reduces medical errors, nosocomial infection, and makes it a better place to work," Zimring observes.

These findings contain a big lesson for quality managers, he notes. "The physical environment matters for quality outcomes, and the quality manager will either be working with or against that physical environment," Zimring asserts. "Many hospitals, even new ones, are simply places that breed errors and infection."

On the other side of the coin, however, facilities that have invested in evidence-based design have reaped real benefits. Bronson Methodist Hospital, for example, used such an approach in the $181 million redevelopment of its hospital campus in downtown Kalamazoo, MI.

The redesign included 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 cited in the report:

  • 11% reduction in nosocomial infections;
  • nursing turnover rates of 6.5%;
  • 95.7% overall patient satisfaction;
  • improved staff satisfaction;
  • 6% increase in market share.

Texas A&M research indicated that such changes increase overall costs by about 5%, "but if you look at it very conservatively, you’d get it back in one year," Zimring adds. (For other examples, see box, below.)

You need QI, too

Zimring concedes that none of these improvements occur in a vacuum.

"You need quality improvement initiatives as well," he observes. "But do you want to work against the building or use it as a tool to make these things easier and more permanent?"

Remember, he says, that what is built today will be in place for decades. "If we do it wrong now, it will haunt us for the rest of our careers or it will help us for the rest of our careers," he notes.

That is precisely why the quality manager should be heavily involved in the design process, he says. "Common sense and research suggest that where you get the biggest bang for your quality buck is if the system and the process design are in concert," Zimring says.

Zimring and Ulrich offer the following recommendations for designing your facility in a way that will support your QI efforts:

  • 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.
  • Improve indoor air quality with well-designed ventilation systems and air filters to prevent nosocomial infection.
  • Use sound-absorbing ceiling tiles and carpeting to reduce noise, which will lower stress for patients and staff alike.
  • Provide better lighting and access to natural light to reduce stress and improve patient safety.
  • Create pleasant, comfortable, and informative environments to relieve stress and promote satisfaction among patients, their families, and staff.
  • Make hospitals easier and less stressful for patients and their families to navigate.
  • Design hospitals that help staff do their jobs.

"We now have 600-plus studies that show the physical environment can be a tool in improving quality, so QI managers should be brought in very early in the design process and throughout the process," Zimring says.

"Quality managers need to know the potential of the physical environment and what the key decisions are," he adds.

Need More Information?

For more information, contact:

• Craig Zimring, PhD, Professor, College of Architecture, Georgia Institute of Technology, Atlanta. Phone: (404) 894-3915. E-mail: craig.zimring@arch.gatech.edu.