Touring the hospital of the future
In designing anything as permanent as a new structure, planners want to be as sure as possible that the building will serve its users well for years and even decades to come. The feat of prognostication, always difficult, is even more so for healthcare, where technologies, patient expectations, and financing situations seem to change at the speed of light. What are healthcare designers to do? What sort of “vision map” might be helpful in guiding their thinking today? Recently HEALTHCARE DESIGN asked three notable healthcare futurists to offer their views on key issues influencing the near and even long-term future of hospital care:
Questions were posed by HEALTHCARE DESIGN Editor Richard L. Peck.
What impact will growing baby-boom utilization have on hospital design?
Jones: Basically, the population growth bubble will have an initial impact on utilization of ambulatory care and discretionary surgery and diagnostics. Then their aging will increase inpatient demand substantially, even considering their overall better health compared with their parents' generation. From a design perspective, hospitals will have to realize the necessity of adding substantial numbers of beds periodically over the next 40 years. Interestingly, though, my architectural friends say they're still being asked, during California's seismic renewal campaign, to build the traditional matchbox-on-a-muffin structure, with no growth plan involved. Planners appear to be ignoring the baby-boom effect and relying on historical experience, forecasting only to opening day.
I admit, I spent most of the 1990s telling people not to add anything because California had twice as many beds as it neededa result of both managed care and substitutions for inpatient care. But health plans have loosened their control in recent years, and hospitals are finding themselves fully occupied, at least in the late fall, winter, and early spring. Some hospitals have known that they've had to grow some elements, such as the ICU and ER, but I don't know of anyone planning to add, say, 200 beds over the next 10 years, then 200 more 10 years after that, even though the total population will double in 30 to 40 years. It's a choice of growing in stages or having other sites to develop separate facilities, or some of both.
If hospitals do decide to grow in this manner, what will the insides look like?
Jones: Hospitals have to plan for a larger ethnic component, and that means accommodating more family members. There might be, for example, sleepover space in every room, a family lounge on every patient floor, and more education space where groups of patients and their families can learn how to care for themselves at home. The family-oriented Hispanic community, for example, has grown not only in California, but also in virtually every area of the United States; some major cities, as well as California, are already “majority minority.” The “patient only” as the “unit of care” is no longer viable; the unit of care now has to be the family.
Not only do rooms have to be larger and accommodate more procedures and in-room counseling, they must be single-bed rooms. Gone are the days when you had to tolerate sharing a room with another sick patient nearby, having your nurses talk to you differently, and having to hear a Code Blue now and then. We've arranged to care for all the less-sick people outside the hospital, so those who remain are really sick and deserve better, more sensitive care.
Isn't this a costly way to build a hospital, though?
Jones: There is actually a trade-off of space involved between departments and nursing floors. Planners can relocate vital services to decentralized areas; it is no longer necessary to build a clinical lab the size of a football field. One can have a lab on each floor and tools for some tests at the bedside. The major diagnostic technology trend is miniaturizationa forehead patch for temperature monitoring, leads built into a vest for EKGsso not as much space is necessary for big equipment as before. The smaller space requirements for central departments and the larger amount of space for nursing floors should net out to the same total area for the hospital, with some exceptions, e.g., changes in programs and pure additions to those diagnostic and treatment services that are large-scale.
Designers will have to start realizing that their software packages that translate admissions into needed laboratory or other diagnosis and treatment (D&T) space are mindless. With patients these days requiring 24-hour monitoring and care, the central “product” of the hospital is the patient room; skimping on that is not a viable approach for those building hospitals today. Moreover, patients expect more amenities and a hotel-like setting.
Where do such new developments as gene therapy and nanotechnology fit into this planning?
Jones: Gene therapy requires a marriage between lab and pharmacy capabilities, and those providers must work together with the attending to craft a custom solution to the patient's problem. We'll have routine DNA analysis of the patient and of the disease organism, and we'll need teaching/planning space, where care providers can meet for consultation, reviewing records on screen, calling up resources from the Internet, and monitoring patients centrally.
Nanotechnology will produce interventions unlike any used today and will not be generated or manufactured on sitethere will be no such thing as a “nanotechnology lab.” The key here will be access to a database of available nanotools, so that one can purchase directly from an R&D lab or manufacturer the specific nanosolution one wants. The space implication is the same as that of gene therapy: room for team consultation around a solid clinical information system.
Does the “digital hospital” that so many are talking about have relevance here?
Jones: We're on the cusp of the digital hospital now, and in 10 years it won't even be a matter for debate. The main vendor strategy right now is to educate future clients. Most CEOs don't know much about digital technology or how to deal with digital vendors, and there are some vendors that are, as one might expect, over-promising. Here's the thing: Hospitals are being planned today with a five-to-seven-year lead time. Those involved in this planning should approach their general digital vendor of choice and say, “We don't want to hear any stories or excuses; we want you to be ready by then and, along the way, give us quarterly progress reports. And we'll work with other vendors, if we have to.” What not to say is, “We will add digital solutions to our analog legacy systems to save money.”
A wholly new hospital can have design features that grow out of digital technology that could not be accomplished by maintaining a dual system, especially one with paper charts. For example, if all diagnostic services are digital, the physicians who read the results need not be in the same location as the image creation; the results can be read anywhereon the floor, at bedside, or in Dallas. Moreover, with images stored on a server, large spaces for film storage will be unnecessary.
The other important point about the new healthcare information system is that its chassis should be clinical. You'll recall that computers first made their appearance through the business side of the hospitalfinance, human resources, admitting. No one dreamed in the early years that computers would be directly useful in managing care, nor did care appear to need managing in exquisite detail. Now we know that both are true, and not only that, but that the clinical information contains the necessary information for billing, not the other way around.
What's more, with today's staffing realities, the key to the future is substituting capital for labor, and a well-thought-out information technology (IT) system is the best way to get there.
IT vendors often throw the digital hospital decision back to customers, saying they really have to reorganize themselves to gain the best use of information technology. Your view?
Jones: They're right; the hospital has to move from a departmental organization to a clinical program- and functional system-based organization.
That's a tall order, isn't it?
Jones: It is and it isn't. The new approach is a simple concept, in which one manages the total set of services received by a patient throughout a course of illness, against a protocol that is a component of approved insurance contracts. The work of the healthcare organi-zation is clinical, drawing on support services organized in systems, rather than departments. Each “system” (human resources, IT, finance, etc.) serves all the clinical programs as an outside vendor would; they don't concoct their own game plans. The operating budget with 50 operating departments, each one with its own expense structure, and no clear way of associating their costs with particular patients, nor with the revenue associated with those patients, is an artifact of our precomputer past.
But the old “tribal” organization is still hardwired into our culture. At the top is the tribal warrior leader, the band of hunters are beneath him, and the serfs are back in the village keeping things going day to day. This organizational approach is something we've inherited and lived with, and now we know that it doesn't work.
It's surprising, the primitive level at which many hospital organizations still are found. The U.S. Department of Defense in the McNamara yearsthe 1960srequired all its vendors to organize by program and by system because the federal government didn't want to pay for any sloppy overhead that wasn't directly connected to the project at hand. Hospitals don't think like that; they think their economics are adequately explained at the total hospital level, so this has kept them from modernizing and pushing the decision making and control down the organization. Today's departmental fiefdoms have been infantilized to be responsible only for expenses, not revenues. There is a belief that the clinical staff cannot handle the business side of healthcare and that such considerations should not interfere with a pure clinical decision process. In effect, it means that the CEO and CFO are making the revenue decisions while the programs are making the expense decisions. If this were any high-tech manufacturer or major retailer, such a segregation of responsibilities would be laughable.
What about the notion that healthcare and, by extension, healthcare design are really consumer-driven these days? And what about the countervailing view that it's really the doctors, with their admitting privileges, who have the most say?
Jones: Consumers care about the hotel functions and physicians care about the medical technology functions. The amount of influence from each, though, depends on the type of patient involved. Obstetrics patients will shop around, even to the extent of changing physicians if they feel strongly enough about the hospital. Obviously, for the cardiac patient who is unable to act, someone else decides. The situation is all over the place. Evidence does show, though, that the new, shiny, pretty hospital does attract both patients and physicians, and even symbolizes high quality, whether or not it's there. The question should be, “Should hospital design incorporate an understanding not only of the patient as patient, but the patient as consumer?” The answer to that is an easy “Yes.” I believe strongly that any healthcare architect should be prepared to bring to the hospital some well-thought-out consumer- satisfying design concepts that are functional and related to interior design (e.g., punctuating long corridors with seating areas for tired seniors).
Will this new approach to hospital design have a positive impact on the bottom line?
Jones: Yes, but the answer is somewhat more complicated than that. Actually, for the first few years, any new hospital can expect a jump in expenses related to debt service, with a resulting increase in prices and problems with their health plans. Health plans are used to capital costs being at about 6% of budget, but today's 350-bed hospital will come in at about $1 million per bed, with resulting increased debt service. It will raise capital costs to between 8 and 12% of bud-get, of which 3 percentage points will represent equipment costs. Eventually inflation will increase revenues while the debt service remains in the dollar amounts of the original bond issue, and profits will naturally rise. In other words, hospitals shouldn't shortchange good hospital design, since capital costs are not the critical element of the budgetlabor is. Plus, it is unwise to put off new construction because one “can't afford it now.” Construction costs will continue to climb beyond any hope of achieving any savings by waiting. The solution is not waiting, but finding a different solution to capital than borrowing, and there are somee.g., the real estate investment trust (REIT) model in which the physical plant is owned by a develop-er while the clinical operation is managed by a not-for-profit.
In general, the entire architectural, construction, and design world has done a terrible job of educating its would-be healthcare clients about these economic realities. It is as though these entities assume that their CEO clients, who perhaps have never built a hospital in their whole careers, know more than they do about hospital development, even though these architects may have led literally dozens of new hospital projects. The design industry should muster a collective will to raise the expectations, decision-making skills, and project-management abilities of the healthcare industryor watch its members waste billions on “1970s” hospitals.
What impact will growing baby-boom utilization have on hospital design?
Goldsmith: I think there is a lot of misperception on this issue. The oldest baby boomers are 57 this year, and the modal boomer is 47. A lot of what's happening in healthcare today is not driven by demographics but by physicians' response to malpractice patterns. That is, they're telling patients to go to the ER if they need immediate attention and, if they need the physician, the ER will call. What does seem to be driven by baby boomers is the growth we've seen recently in elective diagnostic proceduressports medicine examinations, colonoscopies, and so forth. The strategic issue here is whether hospitals are going to be serious players in this field; hospitals have been yielding to physician practices in providing these services. Hospitals controlled 90% of ambulatory surgery 20 years ago; now it's half. Many hospitals are trying to market both inpatient and outpatient services through the same facility, and this is where they get into trouble, because they have well patients bumping into sick patients, which is not very satisfying to either. Those organizations that have created a zoned, freestanding area for ambulatory patients have been pleased with the results and are quite a success story.
What about the impact of nano- and gene technologies on design?
Goldsmith: Nano is a mirageI don't see anything happening in the near future that has any design implications. The same is very nearly true of genetics. As it morphs from a diagnostic discipline to a therapeutic discipline, there may be a need for the lab and pharmacy to work more closely togethera colocation issue. But whether colocation will be needed or whether more tightly woven information systems will provide the necessary communication is still an open question.
Are there other technologies that might have an impact?
Goldsmith: One issue will be how to size the operating suite to accommodate real-time imaging, robotic technology, telemetry, voice response, and other data transmission. Where do you put the control rooms, for one thing? Do they even have to be on-site? Then we have the question of wireless communicationsfor example, there's tremendous demand by physicians to be able to use their PDAs as “control panels” for patient care. The problem is that hospitals are an almost unbelievably hostile environment for wireless; there are various types of shielding, rebar, elevator stacks, and equipment putting out practically lethal amounts of radio frequencyit's a wonder the people working there don't develop sunburn! Seriously, we need a lot of help with the technology here.
What about the “digital hospital” that everyone talks aboutis that a design issue, in your view?
Goldsmith: Digitizing clinical processes doesn't have immediately obvious design im-plications. It's not clear how much different a “digital hospital” would look from a “nondigital” one. There might be issues concerning building smart voice-response technology into the walls and ways to avoid compromising the communications environment, as I've alluded to. I don't think people were thinking about these issues when they planned their radiology suites.
Do you think design might have some implications for the staffing problem?
Goldsmith: The healing environment is for the staff, too. You can design intelligently to reduce stress, and the leverage to do that comes from IT. If you can deliver information while minimizing the paper and phone chase, and the nurse can spend 80% of her time nursing, she will want to stay there. The same general idea goes for physicians, too.
What do you think of the view that much design change in the future will be consumer-driven?
Goldsmith: Healthcare is always consumer-driven. The recent backlash against managed care is the latest evidence of that. People want to feel they're in control of decisions that affect their lives; they want to be treated better, with dignity and a caring approach. And, on the ambulatory side, there is a class of patients who don't want to be treated as though they're sick. Yes, patients do go to hospitals where their physicians have privileges, but they will change physicians if they feel they have to for better treatment as individuals.
Do you see any conflict in hospitals trying to be both science- and hospitality-oriented?
Goldsmith: I don't think these are mutually exclusive. Some of the finest hospitals I know are among the most beautiful facilities I've seen. Look at Northwestern Memorial Hospital in Chicago; look at St. Vincent's in Portland, Oregon, which I consider to be one of the most beautiful hospitals in the world. These places know that you have to look beyond a sort of grim functionalism and create an environment that lifts people up. It doesn't dwarf the patient and the physician; it surrounds them with a calm feeling of competencea healing environment. It's not about machines; it's about people. I admit, I continue to be frustrated by the triumph of grim functionalism in hospital design. These aren't prisons; they're healing enterprises, and I don't think enough thought is being given to this, even yet.
What impact will growing baby-boom utilization have on hospital design?
Coile: This cohort is just starting to reach the age of experiencing health issues, but it will be the number-one consumer driver of healthcare for the next 30 years. We're talking about 78 million people concentrated in a 20-year time span. This will be the fussiest, best-informed group of consumers that healthcare has ever knownand probably more demanding. A study by Press Ganey Associates, Inc., more than two years ago of one million consumer satisfaction surveys found patient satisfaction varying according to age group; patients over 50 years of age at that time were statistically more likely to be satisfied with their hospital stays than younger age groups. This may also be the healthiest, or at least the most health-aware, population that healthcare has ever served. There are some hints that elective diagnostic and surgical procedures are picking up. Freestanding outpatient imaging centers alone increased in number by 25%from 3,000 to 4,000between 1999 and 2001. Will there actually be lower demand for hospital care and shorter lengths of stay? We really don't know at this point.
How might designers accommodate the pace of technologic change, as with gene therapy and nanotechnology?
Coile: The advent of new technologies is the second great force influencing this field. There have been both a higher level of spending on new hospital technologyreflecting the rebounding financial health of hospitals in recent yearsand new technologic developments. There's thinking that genomics may lead to more drug therapies, more personalized treatment, and even organ reconstruction based on one's own genetic code, but it's possible that these treatments will be delivered on an ambulatory basis. There may be specialized laboratories for monitoring treatment and perhaps even precautionary confinements in hospitals, at least during the early years, but again, this is unknown.
The demand for surgery will be very strong, what with implants, drug-coated stents, and specialized cardiac assist devices such as Vice-President Cheney uses, so we're not sure how many operating rooms will be needed. In terms of total facilities, I suspect we'll see an increase from the levels of the 1980s and 1990s, but probably not to the levels of years previous. For sure many communities that are attracting new arrivals, such as retirement areas, are not only upgrading their old hospitals, but also building new ones to accommodate the demand.
What will it take to make the “digital hospital” a reality?
Coile: As it happens, I recently visited the first digital hospital in the United States, the Indi-ana Heart Hospital. Although it is primarily a cardiac-care facility, it provides a variety of services in its 88 beds. I got a demonstration of its paperless, touch-screen technology and its PDAs and handheld laptops for use by physicians. It's not entirely paperlessthere are pieces of paper, no doubt, but they won't last long. Paper healthcare records that come in on admission, for example, are all scanned into the hospital IT system and shredded. There's no medical record library at the hospitalthere's a computer room. There is one IT specialist on each unit, for a total of eight. That sounds like quite a few, but they're being kept busy working with those physicians who are not yet computer savvy.
What does this mean financially? For starters, the hospital's capital budget for IT is probably double that of the average hospital's, and its operating budget is at least 50% higher, if not double. But the hospital is looking for financial returns in increased productivity, less paperwork, and less redundancy of services. They won't, for example, have nurses and physicians repeating each other's work on, say, history and physicals, because the records are immediately available to caregivers electronically. Savings are also anticipated from reduced medical errors.
Interestingly, this is a joint venture between a not-for-profit organization, the Community Health Network of Indianapolis, and a for-profit physician's group called Heart Associates of Indianapolis, so the physicians have a financial stake in this.
Will consumer-directed care continue as a trend and, if so, what will this mean for hospital design?
Coile: The data I've seen indicate that patients make the hospital choices about half the time. Also influencing this is the fact that managed care has largely stopped telling people what hospitals to go to. Patient-centered care models have been around for a whilethe Planetree model, for example, now based in Derby, Connecticut, began in San Francisco in 1978. Its central principles have been to organize care around the individual patient and provide care with minimal disruptions, fewer transfers, and the like. We also have the healing-environment movement led by The Center for Health Design over the past 10 years or so, again with patient-centered care as its focus. So, in general, this trend will continue and will have a profound influence on design.
How, in general, will the hospital of the future combine science-based medicine and hospitality?
Coile: It's interesting that movements like Planetree were almost antitechnology at the start, but now we're learning that you can combine high tech and high touch. For example, we now have ICUs with floor-to-ceiling glass, accommodations for families, and larger spaces in general. Patients in some hospital rooms can now control their lighting, sound environment, and window shades directly from their beds. Also, with miniaturization, technology is easier to hide. At the digital hospital in Indianapolis, all the beds are “digital,” with patients being telemetrically tracked without their even being aware of it. We're also seeing the growth of family-centered care in ERs, which are becoming much larger and yet more private. So the trends of high tech and high touch aren't necessarily mutually exclusive. HD
Wanda J. Jones, MPH, president of the New Century Healthcare Institute, San Francisco, California, and author of several position papers on the future of hos-pitals, including the recently published “California's Hospitals' ‘Renewal By Earthquake’ 21st Century Hospital Design Concepts.”
Jeff Goldsmith, president of Health Futures, Inc., Charlottesville, Virginia, a firm that has specialized for 20 years in corporate strategic planning and forecasting of future healthcare trends.
Russell C. Coile, Jr., editor of Russ Coile's Health Trends, and a national consultant and speaker on the future of healthcare.