Despite deep and vocal disagreements over healthcare reform, virtually everyone believes that the current system is not economically sustainable. We are spending too much and getting too little in return. This recognition has spurred healthcare leaders to examine every aspect of hospital operations. But what about the healthcare building itself, the physical environment within which patient care occurs? Too often, cost-cutting discussions have overlooked the hospital structure. Changes in the physical facility provide real opportunities for improving patient and worker safety and quality while reducing operating costs.
The “Fable” hospital, an imaginary amalgam of the best design innovations that had been implemented and measured by leading organizations, was an early attempt to analyze the economic impact of designing and building an optimal hospital facility. The Fable analysis, published in 2004, showed that carefully selected design innovations, though they may cost more initially, could return the incremental investment in one year by reducing operating costs and increasing revenues. Reactions to the Fable paper varied. Many felt it presented a compelling case and stimulated healthcare leaders and architects to think differently about balancing one-time building costs with ongoing operating costs. Others voiced skepticism about whether the benefits were as great as described and asked for more evidence.
Today, the Fable hospital is no longer imaginary. During the past six years, numerous hospitals have implemented many of its attributes and have evaluated their impact on patients, families, and staff. Several are members of The Center for Health Design's Pebble Project, a group of organizations that apply evidence-based designs to improve quality and financial performance. Two Pebble hospitals-Dublin Methodist Hospital and Sacred Heart Medical Center at RiverBend-are featured in essays accompanying the complete version of this article in The Hastings Center Report.
These and other pioneering organizations and their architecture/design teams are introducing such interventions as larger single-patient rooms, which reduce the incidence of healthcare-associated infections; wider bathroom doors, which reduce patient falls; HEPA filtration and other indoor air quality improvements, which reduce healthcare-associated infections; appropriate task lighting in medication dispensing areas, which reduces medication-related errors; hydraulic ceiling lifts in patient rooms and bathrooms, which reduce patient and staff lift injuries; and art and music, which reduce anxiety and depression, and speed recovery.
Since 2004, much has changed that affects decision-making about healthcare construction and design. It is time for a fresh look at the Fable hospital. Drawing on the latest design and healthcare knowledge, research, the 2010 health reform law's emphasis on value and quality improvement, and our collective experience, we present Fable hospital 2.0.
The changing healthcare landscape
Five major healthcare trends are relevant to our analysis: the growth of evidence-based design, the safety/quality revolution, pay for performance and increasing consumer transparency, sustainability and green design, and access to capital.
The growth of evidence-based design. The Center for Health Design's definition of evidence-based design is “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” That evidence is much more abundant. In 1998, a review found fewer than 100 solid studies. A 2004 analysis found more than 600 worthy studies.4 In 2008, a team found 1,200 methodologically sound studies.
Facility design guided by credible research has become the standard for architects and designers, as witnessed by conferences focused on evidence-based design and the appearance of new publications.6 More than 500 healthcare and design professionals have been accredited by The Center's Evidence-Based Design Accreditation and Certification program, which was launched in 2009. Although the growth of evidence-based design has provided considerable guidance, other evidence comes from management, finance, computer science, human resources, ergonomics, supply chain distribution, and conservation.