Evidence-based design researcher Roger Ulrich, PhD, sat down with Sara O. Marberry in Chicago at the Hyatt Rosemont after a Center for Health Design board meeting. In the first part of her interview with him (published in the November 2010 edition of HEALTHCARE DESIGN ), the two discussed how his own interest in healthcare design research was first piqued, his place as the “father” of evidence-based design (EBD), where we are today in regard to research in the field, and the misconceptions that still surround EBD.

In the second installment, Ulrich shares what he considers to be his most interesting projects, details on what is keeping him busy today, and examples of what he believes the United States would benefit from learning about healthcare from international counterparts.

Sara O. Marberry: What's the most interesting research project you've ever worked on?

Roger Ulrich, PhD: Whatever I'm working on at the present. Looking back a few years, one was a study of the effect of different kinds of art on patients who had just undergone coronary bypass surgery. To our surprise, we found that abstract art made people sicker than if they had no art at all. Another interesting one was when Robert Simons at the University of Delaware and I studied the effects daytime television played in waiting areas on stress for blood donors. The research showed that the widespread practice of playing daytime television continuously and uncontrollably in waiting areas increases blood pressure and heart rate and can worsen stress.

I love the learning and sense of discovery that comes with research. Projects are particularly interesting when there is an interdisciplinary team of bright, nice people from whom I learn a lot. When researchers from different fields work together, the range and depth of expertise makes it possible to carry out work that no individual investigator, however talented, could ever do on their own. There also can be an inspiring creative chemistry when open-minded folks from different fields work together. A few years ago, I participated in a study in Sweden on the effects of noise on patients in the throes of acute myocardial infarction. It was a memorable project that involved a diverse research team with different talents, including cardiologists and stress researchers.

Marberry: How about the most interesting consulting project that you've worked on?

Ulrich: In 2005-2006, I took a sabbatical from Texas A&M and worked in London as a senior advisor for the U.K. National Health Service (NHS). Basically, my job was to bring evidence-based design to the NHS. At that time, it was the world's single largest healthcare design and construction program, totaling many billions of pounds. My position gave me access to the highest levels of government but had no real direct power. It soon became evident, though, that if my arguments were good and backed up by good evidence, it was possible to change how hospitals were designed.

When I arrived in early 2005, the percentage of single rooms in new NHS hospitals was very low, typically no more than 15 or 20%. The first round of new construction had just been finished, and some of the buildings were disappointing. A major problem was that the rates of infections such as MRSA and C. difficile continued to rise. By the 2005 U.K. general election, “killer bugs” had become the No. 1 political issue in the country. The war in Iraq was the second. Overall, it was an incredible learning experience for me-to leave my own academic “duck pond” in Texas, and land in the maelstrom of British politics and healthcare. When I left in 2006, the first hospital brief, or program, had gone out with 100% single bed rooms and others required 80%.

Marberry: What are you currently working on?

Roger: I'm currently working on a project with Xiaobo Quan that examines whether certain changes in patient-room design increase staff handwashing. Another is a new project to see if changes in the design of emergency rooms can reduce the major problem of physical violence. This is a multi-year study involving several people.

Marberry: And what about your new affiliation with Chalmers University in Sweden?

Ulrich: I've been appointed part-time professor of evidence-based design at the Swedish National Center for Healthcare Building Research, which is housed at Chalmers University in Gothenburg. My role is mainly as a researcher. The position has been designed so the work does not interfere with my teaching at Texas A&M.

Marberry: What would you advise a project team that's just starting to plan a new hospital?

Ulrich: The first thing would be to get EDAC-accredited. I recently visited the Vancouver Island Health Authority in British Columbia, Canada, where members of the client's project-development team for the new Royal Jubilee Hospital are EDAC accredited. This includes facility managers, nurses, even a finance person. Knowledge learned from EDAC has clearly contributed to quality and innovation in the Royal Jubilee design. Another valuable thing to do is to join the Pebble Project and learn from the experiences, processes, and research of more than 40 innovative hospitals and systems. In addition, identify some exemplary facilities and assign time and resources to conduct onsite visits, including meeting with some of the hospital staff. Finally, hire a design firm with in-depth expertise in evidence-based design and a track record of projects with EBD features.

Marberry: Where do you see yourself in 10 years?

Ulrich: I'll be semi-retired, but will still be doing research and teaching. My main location will probably be in Scandinavia since my extended family is there, but I will maintain close ties with the States. I have no plans to quit doing research and writing.

Marberry: What are some of the lessons that we can learn in the U.S. from our international counterparts?

Ulrich: Every other advanced country has a healthcare system that outperforms ours on measures of efficiency, equitability, certainly cost, and often quality of outcomes. Yet I think the American system, despite its weaknesses, has strengths and has taught the world some important things. One is the importance of service quality, paying attention to patient satisfaction, and treating patients as customers and persons. U.S. hospitals also have been among the world leaders in encouraging the presence of families. Another very important one is the benefit of having competition. Other advanced countries, with the exception of Canada, have moved to hybrid systems, having competition and a mix of public and private providers.

Having worked or spent time in exceptionally high-performing systems, such as Denmark, Sweden, and the Netherlands, one of the most important things I've learned is that American healthcare suffers a lot because the system is so fragmented. The fragmentation increases burdens for our hospitals and providers, worsens outcomes for patients, and greatly increases costs. For example, if an ICU patient in a U.S. hospital develops a staph infection, according to the Centers for Disease Control, more than 60% of the time that infection will be antibiotic-resistant and therefore very serious. It will certainly harm the patient and keep them in the ICU and hospital a lot longer, add tremendously to costs, and worsen the patient's risk of dying.

By contrast, if an ICU patient in a Swedish, Danish, or Dutch hospital gets a staph infection, the odds of it being antibiotic-resistant are only about 1% or 2% in large cities, and usually less than 1% in other areas. And rates for other types of resistant infections are lower than in the states. How is that possible? I think the poor performance of the U.S. compared to these other countries stems mostly from the fragmentation of our system. It is not the case
that American hospitals are performing worse than those in Sweden, Denmark, or Holland-in fact, many U.S. hospitals are outstanding. But in the case of efforts to prevent multidrug-resistant infections, the high-performing countries operate cohesively at the system level to reduce risk, and hospitals cooperate or work together. This team or cooperative approach coexists harmoniously with aggressive competition among hospitals for patients and revenues.

Marberry: How does this work?

Ulrich: Well, if a hospital in the Netherlands has an outbreak of MRSA or resistant staph, the system policy requires that whatever it takes must be done to search out the origin of the outbreak and completely eradicate it. This involves detective work by microbiologists, and could mean closing entire wards or possibly putting on paid leave a clinician who is found to carry the bacteria in their nose. The staff member might need to receive pay and stay home for several weeks until cleared to return. When I was in the Netherlands six years ago, the average cost of a search and destroy episode was about 1.5 million euros. That's a huge cost that no individual U.S. hospital could afford for long because our system is fragmented. The Dutch Health Council, that country's counterpart to the Institute of Medicine, did a cost-benefit study to find out if the high cost of search and destroy was justified. The study concluded that search and destroy saved large amounts of money over a period of several years because it helped to substantially reduce infection across the system. In high-performing and safe healthcare systems such as the Netherlands, the costs of search and destroy and other expensive measures for reducing infections are partly borne by the individual hospital, but also shared across hospitals and the system because preventing resistant infections is considered a valuable public good that benefits all hospitals and patients.

Marberry: Besides search and destroy, what else do they do?

Ulrich: The systems in Sweden, Denmark, and Holland all operate in unfragmented cohesive ways to reduce unnecessary prescriptions of antibiotics. They also have electronic medical records. In fact, Sweden has had a national electronic medical record since 1994. Another major advantage these countries have compared to the U.S. in controlling resistant infections is that they all strictly limit the use of antibiotics in livestock.

Fighting infection is a bit analogous to fighting a war against insurgents, which are hidden and endemic in communities. Imagine a country with superb individual troops with the world's best training, and the most expensive and best equipment. Assume that every one of these elite soldiers is highly skilled and dedicated. These strengths are negated, though, by the fact that when the troops go into combat against a stubborn foe, the army's system prevents soldiers from working together as a cohesive unit. In fact, the system requires soldiers to compete against each other, not share information when in combat, and not help each other when one gets wounded. There are no medals for individual heroism on behalf of fellow soldiers or the unit. Such behavior is discouraged by financial penalties. This hypothetical army would be extremely expensive, but ineffective and would often lose.

By comparison, a less well-funded and well-equipped smaller army of less-skilled individual troops who cooperate as a team will perform better and often win. This example of hypothetical armies points to a dramatic strategic difference that I see between certain high-performing systems in Europe and the U.S. system. The problem of fragmentation was not adequately addressed in the recent U.S. healthcare reform debate.

Marberry: What do you want your legacy to be?

Ulrich: That I contributed to research on the importance of nature for reducing patient stress and pain; was a leader in documenting the benefits of single-bed rooms versus multibed rooms; and that my collective research, teaching, and service activities helped foster the design of more healing and safer healthcare environments.

Sara Marberry is the executive vice president and COO of The Center for Health Design. For more information, visit www.healthdesign.org. Healthcare Design 2010 December;10(12):38-41