Strategic, evidence-informed design: The world's first elder-friendly acute care hospital
The Vancouver Island Health Authority is creating the world's first elder-friendly acute care hospital to support its goal to become a Centre for Excellence in Seniors Care. While it is well understood that care, and caring, have requirements and inputs that reach far beyond the built form alone, and to support the notion that the physical environment can place severe restrictions on a provider's abilities to provide care and causes physical and emotional harm to older adults, we believe that the design of acute care units must be carefully contemplated and evaluated against how elder friendly they are.
The Patient Care Centre
The Patient Care Centre is a 500-bed inpatient facility scheduled to open in early 2011. It is currently under construction at the Royal Jubilee Hospital site in Victoria, British Columbia, Canada. This $280-million project will deliver an eight-story tower where medical, surgical, and mental health inpatients will be cared for. The Royal Jubilee is one of several acute care hospitals operated by the Vancouver Island Health Authority (VIHA), which is a publicly owned, funded, and operated healthcare system.
Through a network of hospitals, clinics, public health units, and residential care facilities, VIHA provides healthcare to over 752,000 people on Vancouver Island, on the islands of the Georgia Strait, and in the mainland communities north of Powell River and south of Rivers Inlet (17% of British Columbia's population, within an area of 56,000 square kilometers). The Royal Jubilee Hospital serves as both the tertiary referral centre for the entire area, and as a regional hospital for the southern third of the authority.
Strategic evidence-informed design
As a new facility with a design life of a minimum of 50 years, planning for the patient care centre had to contemplate the delivery of acute care services in the period 2010 through 2060, a time during which the baby boomers, who currently comprise 31% of the residents served by VIHA, will enter old age and end of life. By establishing the strategic objective of becoming elder friendly right from conceptualization, all involved in the project have been required to select, evaluate, and analyze the evidence and consider the impact of this evidence on the design through the distinctive lens of an older adult. This process of setting out a strategic design outcome, and driving the process to achieve it using evidence, has been coined at VIHA as strategic evidence-informed design (SEID).
Changing demographics make elder friendly a necessity
At a time when many hospitals are challenged with capacity and access issues, and with the largest cohort of baby boomers nearing age 60, healthcare planners must anticipate a future where services will be in even more demand. A notable distinction for VIHA is the age of our residents. VIHA provides more care to an elderly population than the rest of British Columbia and Canada as a whole, with a demographic profile most closely resembling that of Western Europe, in which those aged 75 and up comprise almost 8% of the total population. About 8.7% of the people served by VIHA are 75 years old, or older, compared to 6.6% for the remainder of British Columbia (VIHA, 2007).
Statistics Canada (2006) data reveals that adults age 65 and older are three times more likely to be hospitalized than those under the age of 65. Not only are these older adults being admitted to acute care in greater numbers, but also they are staying an average of six days longer than their under-65 counterparts. The average length of stay increases further—to 14 days—for people aged 85 years and older, and this is often attributed to the results of chronic health problems, functional disabilities, and age-related physiological changes (Parke, 2007, unpublished). At the Royal Jubilee Hospital, people aged 75 years and older accounted for 41% of inpatient days in 2006 and 2007; by 2011 this population is expected to increase to 50% of inpatient days. Over the next 40 years, the population of adults aged 85 years and older is projected to quadruple (Parke, 2007, unpublished), compelling healthcare systems to think strategically about how they will prepare to meet the needs within their communities.
The traditional acute care hospital
Acute care hospitals of the past, including the Royal Jubilee, were designed to provide care to adults who were suffering from a single identifiable medical condition. This resulted in an environment that is provider-centric and where interventions and treatments are done to patients. The physical plant was based on ease of cleaning, supervision, and visibility. Little if any attention was paid to privacy, autonomy, family involvement in care, and self care. These design features were not valued as elements that would contribute to healing in an intervention-based model of care. The results are hospitals that have shared bedrooms and bathrooms, bright florescent lighting, high-gloss, durable flooring, multiple sources of noise, strict visiting protocols, and narrow spaces that only able-bodied healthcare professionals can navigate within.
Healthcare environments should heal and if this cannot be achieved, then at a minimum they should do no harm (Hancock, 1999; Ulrich et al., 2004). The result of the traditional hospital environment for older adults is often a decline in functional ability and many unintentional and deleterious outcomes such as delirium, infection, and pressure sores (Creditor, 1993; Parke, 2007, unpublished).
The evidence-informed, elder-friendly, acute care hospital
Setting the strategic objective for an elder-friendly hospital required the project team to work backwards from the future state, namely from the question: If we had an environment that was perfectly elder friendly, what would it look like?
The growing body of evidence regarding healthcare design, together with knowledge from the domain of gerontology and long-term care settings, provided ample data from which to inform the answers to this question. Elements such as textures, colors, use of contrast, lighting placement, avoidance of tripping hazards, wayfinding strategies, and circulation routes all contribute to a physical environment that, at least, does not harm older adults. Furthermore, such an environment aids in healing and, when used throughout the entire building, will enable older adults to maintain functional ability to the greatest degree possible.
It is worth noting that incorporating these design principles early in the planning process did not increase capital costs. This is consistent with the findings of others who advocate for the use of evidence-based design.
Elder friendly: A new dimension of universal design
Creating an elder-friendly hospital will result in a facility that is universally accessible. By considering the psychological changes that occur with aging, and by designing an environment that is responsive and complementary to these, the built form inherently becomes safer and more responsive to the needs of anyone who has cognitive or physical vulnerabilities, whether this vulnerability occurs as a result of an accident, illness, or medical intervention and regardless of age.
A wide range of elder-friendly design elements were sourced by the project team from a variety of sources including VIHA consulting geriatricians; VIHA clinical staff; multilevel-care design guidelines (Ministry of Health and Ministry Responsible for Seniors, 1994); an evidence-based practice review commissioned from the University of Victoria Centre for Aging (Parke, 2007 unpublished); Code Plus, a guide to support decision making developed by Fraser Health Authority (Parke & Friesen, 2007); resources from The Center for Health Design, specifically from the Pebble Project; and the literature cited.
This approached provided the project team with a wide range of options that allowed us to combine best practices and evidence together with what we knew was currently working well within our own health authority and our programs. Having a pool of elder-friendly design elements from which to pull from allowed us to be fully informed as we engaged with our design team, ensuring that the final design would indeed fit well with our practice context.
Some of the more salient of these elder-friendly design features include:
Doors that slide open, rather than swing into the walking path of the use
Lever-style door knobs that do not require a grip or twisting action
Window blinds, thermostats, and light switches that can be accessed from either a standing or sitting position
Family zones in all bedrooms
Toilets placed so assistance can be provided from either the patient's right or left side
Shower stalls that allow for wheeled access
Lighting placed strategically to avoid glare against signs, work surfaces, and flooring
Use of color to highlight the contrast between the edge of floors and walls
Use of color to disguise out-of-bounds, or back-of-house, spaces
Quality places to mobilize to and socialize within (e.g., gardens, places to make a cup of tea, family lounges, and mobilizing paths within the unit)
Handrails in bedrooms, bathrooms, inpatient unit hallways, lobbies, and outside spaces to promote independence
A universal floor plate across the various inpatient services (respiratory, nephrology, cardiology, for example) that promotes familiarity and wayfinding via repetition
Seating placed throughout hallways, in elevator lobbies, and adjacent to all “decision points,” as individuals navigate the building
A quiet hospital, one that does not use overhead paging or a nurse call system that is audible unit-wide
Elder centric: Future proofing the Patient Care Centre
One of the challenges of building a new hospital is that the facility will still be in use long after current thinking and knowledge that influenced the design process has evolved. Models of care will continue to transform, influenced greatly by advances in technology, new knowledge in both medicine and nursing, and changing societal attitudes.
Creating an environment that will be compatible to these changes cannot be guaranteed, however, we believe that by planning for the needs of older adults throughout the facility; by borrowing from the design concepts of long-term care settings; by creating spaces that are flexible and universal; and by allowing evidence to inform our decisions, the patient care centre will stand a greater chance of meeting the future needs of our community, whatever they may be. HD
- Creditor M, Hazards of hospitalization of the elderly. Annals of Internal Medicine 1993; 118:219-233.
- Hancock T. Creating healthy and health promoting hospitals: A worthy challenge for the twenty-first century. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services 1999; 12 (2): viii-xviii.
- Ministry of Health and Ministry Responsible for Seniors. Multilevel care design guidelines. Facilities Planning and Construction Division, Ministry of Health and Ministry Responsible for Seniors. Province of British Columbia, 1994.
- Parke B. Physical design dimension of an elder-friendly hospital: An evidence-based review undertaken for the Vancouver Island Health Authority. University of Victoria Centre on Aging:Unpublished, 2007.
- Parke B, Friesen K. Code plus physical design components for an elder friendly hospital. Fraser Health Authority 2007. Retrieved August 2008 from http://www.fraserhealth.ca/News/Publications/Pages/Code%20Plus.aspx
- Statistics Canada. Canadian Census. Ottawa:Health and Welfare Canada 2006.
- Ulrich R, Quan X, Zimring C, et al., The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity, 2004. Retrieved August 2008 from http://www.healthdesign.org./research/reports
- Vancouver Island Health Authority.The Vancouver Island Health Authority 5-Year Strategic Plan, 2007. Retrieved August 2008 from http://www.viha.ca/NR/rdonlyres/0496C63E-96FE-4A36-852F-20E408AA02AB/0/five_year_strategic_plan_updates_2007v_5.pdf