Palomar Medical Center West Escondido, Ca

Palomar Medical Center West Escondido, Ca

As has become clear in recent years, the design profession, together with nonprofit groups committed to improving care, has begun to fundamentally change the physical environment of healthcare facilities to achieve better clinical outcomes within safe, sustainable, and flexible environments. A new generation of evidence-based design for healthcare facilities has emerged, informed by extensive consultation with healthcare professionals and leading experts in related and tangential fields. The current challenge is determining how healthcare institutions can leverage this new architectural platform to maximum effect. As institutions transition from existing facilities, they grapple with the realities of staff culture, training and skill sets, regulatory requirements, and reimbursement procedures. If any one of these realities is not in alignment with the larger goals for improvement, the potential positive impact will be diluted, if not undermined.

Take, for example, the design of the patient rooms and units for the new medical center under construction for Palomar Pomerado Health (PPH) in northern San Diego County. Conceptualizing the patient room for this project has raised several questions.

The design was driven by the key objectives of:

  • improving patient and staff safety

  • improving operational efficiency and clinical outcomes

  • incorporating elements that create a sustainable and healing environment

PPH's new patient rooms embrace most, if not all, of the currently known best practices:

  • all-private rooms

  • acuity adaptable

  • same-handed design

  • distributed nursing and storage for supplies and medications

  • robust technologies accommodated

  • connection to nature (distant views and landscaped balconies)

  • patient control over lighting, temperature, privacy, food, and information

  • inclusion of family as part of the care team

  • noninstitutional aesthetic

But challenges have arisen along the way.

Acuity-adaptable care model challenge

The key objective of acuity-adaptable care is to reduce or eliminate the need to transfer patients during their hospital stay. Keeping the patient in the same room or unit retains the continuity of the care team, which in turn will reduce medical errors, improve operational efficiencies, and increase patient satisfaction.

However, operating an acuity-adaptable unit in its pure form requires some degree of cross-training of the nursing staff, which is where difficulties often arise. Nurses often lack the ability and/or desire to provide care to a cross section of acuity levels and diagnoses. As a result, PPH and many other institutions are backing away from the goal of never transferring the patient, to a more achievable goal of transferring the patient only once: from an ICU/step-down unit to an acute care unit. This approach is less radical and can more easily accommodate the realities of training and regulatory tradition. As an improvement over today's practice of multiple transfers, this model may hold potential.

The formal education provided in our nation's nursing schools is acuity-based. High-acuity nurses tend to not want to care for acute care patients. As practice models evolve, the curriculum in schools should respond to these shifts and teach skills required to care for patients in an increasingly complex environment. This means promoting team-based care and fostering teamwork in the hospital environment. Team-based care will also require support from physicians, administrators, and technical staff. In short, the hospital of the future cannot be run by the staff of the past.

In some states, the regulatory infrastructure can stifle design innovation. The acuity-adaptable model of care is not recognized by many states as a viable operations model and thus does not qualify for reimbursement. The prevailing line of reasoning for this states that the presence of one critical care patient on the unit requires the entire unit to be staffed at critical care nurse-to-patient ratios and training levels, thus making the unit unaffordable and unsustainable to operate. Although controversial, it is imperative that the regulatory environment evolve in tandem with practice models.

Distributed nursing/storage challenge

The key objective to distributed nursing care is to allow for most nursing tools and supplies to be kept adjacent to the patient rooms. The idea is to increase the time that a nurse spends on direct patient care, improve patient observation and lead to such desired outcomes as reduced falls and increased patient satisfaction.

Thus far, implementation of distributed care has been more successful than that of acuity-adaptable units. However nurses, by nature, are social beings and like being with other people, and often experience a sense of isolation working in the new model. Personal communication devices, team-based structures, and spaces for team meetings and conference have helped to mitigate this problem. Also, once nurses readapt both culturally and socially, they generally recognize that this model benefits both the patient and the staff.

An associated challenge of the distributed care model is the logistics of stocking and maintaining inventory in the decentralized supply closets on the unit. Rather than stocking one or two areas, as in a traditional unit, the fully distributed model provides one closet per patient room. The questions arise, Who services the closet? and What technologies can support the process? As one option, PPH is exploring the use of robotics and computerized inventory tracking systems, as well as shifting traditional staff roles. In this model for example, the role of the unit secretary might be less administrative and more focused on supporting the unit's logistics and technologies.

Technology challenge

Communication and medical technologies are advancing at a phenomenal clip: There is an 18-month churn to obsolescence. Disruptive technologies-those that fundamentally change how things are done-are occurring at an increasingly rapid pace (robotic and minimally invasive surgeries, for example). The challenge for healthcare institutions is to keep up with these advances-it doesn't help that it takes from five to eight years to build a new hospital. There is a risk of the technology embedded in a facility becoming obsolete even before the doors open.

For architects, the design response is to plan in flexibility, so that over time systems and devices can be accommodated in a strategic manner. Healthcare facility infrastructure must be flexible enough to accommodate structured cabling systems capable of supporting both wired and wireless connections, a converged network platform that supports the facility's various systems (present and future), and a data center capable of providing computing resources for the life of the campus. This design approach can save an institution hundreds of thousands of dollars annually by eliminating duplicated networks and equipment, thus helping to balance the technology/cost equation.

For operations, the response is to plan for evolutionary change versus revolutionary change. New systems take time to implement, and require training, protocols of use, and practice before they are fully embraced by staff. Any new system considered for implementation (EMR, CPOE, Smart ORs etc.) should be piloted in existing facilities, not deferred until the new facility is opened.


The next decade will see the design and construction of many new healthcare facilities. This continued investment offers the opportunity to essentially remake the hospital-to improve care delivery, efficiency, and safety. But effecting positive change in the nation's health system will require more than the good efforts by healthcare institutions and the design profession. The effort must also engage regulatory agencies and nursing and medical schools. Increased collaboration with these entities is needed to provide a better understanding of the challenges and limitations that healthcare providers face in order to truly deliver on the potential improvements available. Without broad commitment and agreement on the key objectives that will guide the hospitals of the future, we will simply freeze today's status quo into place. The progress that is possible is too important to allow this. HD

Graphics courtesy of CO Architects Stephen Yundt, AIA, ACHA, is Planning Principal with CO Architects.

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Healthcare Design 2009 March;9(3):32-36