In the not-too-distant past, healthcare leaders in the midst of constructing a new facility may have decided against adding too many windows in patient areas because of the additional cost. Today, many organizations are deliberately spending more on additional windows because natural light has been shown to improve the healing process—and reduce length of stay and associated costs.
Welcome to patient-centered facility design, which incorporates research on architectural and engineering approaches that positively affect patient outcomes. Patient-centered design is a part of evidence-based design, which also incorporates staff-efficient and energy-efficient features, says Ellen Taylor, director of research, The Center for Health Design, a Concord, Calif., not-for-profit.
“Like treating a patient with evidence-based medicine, we should be designing facilities around the best available information and what we know works, especially when integrated with operational and clinical policies and procedures,” Taylor says.
Indeed, a growing body of research has demonstrated the impact of patient-centered design on clinical outcomes. A 2008 literature review highlights numerous studies showing a strong correlation between reduced hospital-acquired infections and such design elements as large, single patient rooms and improved indoor air quality (Zimring, C.M., et al, “A Review of the Research Literature on Evidence-Based Healthcare Design,” Health Environment Research & Design, 2008, vol. 1, no. 3, pp. 61-125).
Evidence-based design is also proving to be good business. A 2011 analysis found that incorporating evidence-based design elements into a 300-bed hypothetical hospital—including patient-centered features like healing gardens, sound-absorbing materials, and large windows—added an additional $26.2 million to the cost of construction. However, an ROI was achieved in just three years, due to cost savings from reductions in patient falls, lengths of stay, and energy use (see the exhibits below).
“From an investment perspective, if I was a CFO and I was getting a positive return on my facility in three years, I would be pretty happy,” Taylor says.
Built in the 1920s, the New Jersey-based University Medical Center of Princeton at Plainsboro (UMCPP), which is part of Princeton HealthCare System, had been added onto many times over the years. But it still could not meet the technology, service, and care delivery demands of the 21st century.
“Each addition made sense at the time. But if you keep adding on for 60 or 70 years, it doesn’t make any sense by the time you’re done. There was no logic to the layout, and it was extremely inefficient, which gets in the way of creating value and reducing the cost of operations,” says Barry Rabner, president and CEO, Princeton HealthCare System.
In 2003, the health system embarked on creating an entirely new facility. To guide decision making for virtually every aspect of design and construction, Princeton HealthCare System leaders developed a set of principles that focus on goals such as reducing complications, improving clinical outcomes and patient satisfaction, and reducing operating costs. “The principles are almost all about issues that matter to patients,” Rabner says.
The new 630,000-square-foot facility, which opened in May 2012, features many elements that center on improving clinical outcomes and the patient experience. For example, off the hospital’s main lobby, east/west corridors feature all-glass walls that allow natural light to flow in. The hospital’s centers of care are located off these corridors, and most of the services required for each type of care (such as chemotherapy for cancer treatment) are clustered together for easy patient access.
In addition, nursing stations are decentralized, allowing nurses quicker access to patients. “That’s a very patient-centered way of organizing services,” Rabner says.
Designing patient-centered rooms. The best examples of patient-centered design can be found in the 231 private patient rooms, which include various patient safety features and were designed to be virtually identical. “Throughout the building, there’s a huge amount of standardization in design to help reduce medical errors,” Rabner says.
To test and prepare for the new design, two rooms in the old hospital facility were transformed into functional model rooms for the new facility. The model rooms were in operation for about one year. Based on what was learned, about 300 changes were made to the design of patient rooms in the new facility, including:
Even the televisions in patient rooms serve multiple duties. The flat-screen monitors, which are attached to the wall opposite the bed, can be used for viewing entertainment as well as health-education programming, such as videos on hip replacement rehabilitation. The computer also periodically asks patients to rate their pain levels. If the patient is experiencing too much pain, the computer will notify the patient’s nurse directly through a device carried by the nurse. Plus, physicians can access imaging tests from the monitors to show patients their results.
Achieving improvement. The health system has experienced significant improvements in clinical and financial metrics since opening the new hospital in 2012. A host of factors, from better employee training on policies and procedures to new technology, have contributed to these results. But, Rabner says, patient-centered design has played a significant role.
UMCPP now has one of the lowest fall rates, infection rates, and 30-day avoidable readmissions in the state (see the exhibit). Patients also like what they see. UMCPP patient satisfaction (as measured by an independent consulting firm) for overall inpatient services reached the 99th percentile in its New Jersey hospital peer group and near the 90th percentile nationally—the highest scores in the hospital’s history. In 2011, the year before moving into the new facility, UMCPP ranked in the 61st percentile in patient satisfaction in its New Jersey peer group.
In addition, inpatient volume has risen significantly, along with increases in outpatient volumes. Equivalent admissions, which combines inpatient and outpatient services, increased by 6.8 percent from 2012 to 2013. Three-quarters of hospitals statewide saw a decrease in equivalent admissions during the same time period, according to the New Jersey Hospital Association.
Rallying community support. To fund the project, Princeton HealthCare System held a three-year capital campaign that garnered $171 million, about one-third of the project’s $447 million cost and more than three times the targeted goal of $55 million. The remaining capital came from the sale of the old hospital facility, health system savings, operating funds, and issuance of tax-exempt bonds, Rabner says. In addition to the sale of the former hospital, Princeton HealthCare System sold a former skilled nursing facility and several medical office buildings.
Engaging the community and raising funds required two years’ worth of community meetings that centered around explaining the need for a new hospital facility in a new location. Many individual donors touted the amount of planning and intended use of patient-centered and evidence-based design as reasons for support, Rabner says.
Gaining the support of community members by welcoming and listening to feedback was invaluable. “They felt that they were partners with us,” Rabner says.
Expecting a return. Rabner and his financial team have not calculated the cost premium associated with the patient-centered features of the new facility. “However, we definitely expect an ROI on the design decisions that we made,” he says.
The guiding principles that were used in all decision making proved helpful in differentiating what would bring the fastest ROI. “We prioritized those items that we believed would pay for themselves within three years,” he says. “We rejected any design elements that would take 15 years or more to recoup the cost.”
Opened in October 2011, the UW Health Yahara Clinic, Monona, Wis., replaced two older clinic facilities within the University of Wisconsin Hospital and Clinics (UW Health).
The new 32,000-square-foot facility, which UW Health rents for its employed family medicine physicians, includes several features that have helped improve both patient flow and staff workflow, which have led to improved patient satisfaction scores and clinical outcomes.
Removing the wait. A unique feature of the Yahara Clinic is the patient self-rooming process, which is designed to reduce patient waiting times, enhance privacy, and improve staff efficiency. When patients arrive for a physician appointment, rather than going to a waiting room, they proceed directly to an exam room, explains Deborah Lovik-Kuhlemeir, clinic operations manager.
Each exam room has two doors—one accessed from the public corridor used by patients and another back-of-the-clinic door accessed by clinical staff. When the patient is on his way to the room, the receptionist notifies the appropriate caregiver via a note in the EHR and by activating a red light over the room the patient is going to. The caregiver then proceeds to the exam room, as well.
Because the reception area and exam rooms are designed as a hub-and-spoke system, the receptionist can see down all corridors and note when a patient needs help locating a room.
“Patients like it. It does work,” Lovik-Kuhlemeier says.
For the patient, self-rooming reduces wait times and protects privacy by eliminating the possibility of seeing familiar faces in a waiting room. Healthy patients are also kept at a safer distance from unhealthy patients than would be the case if both were sitting in a waiting room.
For the healthcare organization, the approach improves efficiency. Caregivers or other staff do not have to spend time escorting patients, and the exam can begin as soon as the caregiver enters the room. “It’s set up very efficiently,” Lovik-Kuhlemeier says.
Because the clinical workstation area is located near the exam rooms, workflow has improved, as well. The distance from clinical staff workstations to exam rooms has improved by 83 percent compared to the design of the old facilities, according to a study conducted by the design firm (The Center for Health Design, Evidence-Based Design in Practice: Healthcare Design Case Studies from EDAC Champion and Advocate Firms 2014).
Huddling for care. The clinical work station’s proximity to exam rooms means clinical staff, such as medical assistants, are within easy access to physicians. In the old facilities, if physicians needed a medication or some other supply during an exam, they would have had to leave the room and then locate an assistant. Now, they can easily call for an assistant without leaving the room.
“It’s giving me more time to focus on the patient,” says Sandy Kamnetz, MD, vice chair of clinical care for the department of family medicine for the University of Wisconsin School of Medicine and Public Health.
The off-stage/on-stage design also allows for huddle areas, or places away from patients where a small group of clinicians can collaborate in brief sessions to discuss clinical matters, such as schedules, quality improvement projects, or population health management. For example, every week or two, Kamnetz huddles with her team— a nurse and a medical assistant—to review her patients to determine who is not meeting care goals and who is not following up with appropriate care, such as blood tests. The team then discusses possible roadblocks the patient may be facing and strategizes on the appropriate course of action.
At the old facilities, huddles were not possible to do privately and consistently because work stations were in patient-accessible areas. “If we were in our old building, we couldn’t have that discussion in the same space where we worked,” Kamnetz says. “We’d have to schedule that time in another part of the clinic. The new building gives us a space that allows us to work more closely in teams.”
Improving outcomes. The patient-centered design has contributed to more satisfied and healthier patients. Yahara’s patient satisfaction scores have increased by 25 percent since the opening of the new facility.
Patient diabetic measures and hypertension controls have improved, as well. Kamnetz attributes part of the improved clinical outcomes to process changes within UW Health, “But I think the ability for us to huddle makes improvement easier,” Kamnetz says.
Healthcare leaders offer advice on incorporating patient-centered features into new facilities:
Hold a boot camp. Implementing patient-centered design requires a barrage of decision making for which most hospital leaders are ill-prepared. Princeton HealthCare System president and CEO Barry Rabner says project professionals—architects, designers, and contractors—should hold a boot camp for all leaders of the hospital before the decision making begins. This group should include the board, medical staff directors (such as the chairman of surgery), and other senior administrators, such as the chief executive, financial, and nursing officers.
The boot camp should provide a clear understanding of the role of everyone on the design team, the financial implications of decision making, and any operational changes that may be needed to prepare the organization, Rabner says. For example, Princeton HealthCare System hired a government affairs expert because of all the approvals required by municipal agencies for the new facility.
Design for the future. As the importance of population health management intensifies, clinics should include spaces that foster care coordination, says Kamnetz. Caregivers should be able to easily gather in work areas to discuss patient progress, roadblocks, and solutions. These spaces are also used for education of the team and learners, such as medical students.
Space should also be flexible. Offices should hold dual purposes, for example, as private work space for physicians and as places where case managers can meet with patients and social workers.
Realize the value. Although healthcare organizations have recognized the clinical benefits of patient-centered design, Taylor says they are only beginning to calculate the direct financial implications. The growing payer focus on value and quality is causing organizations to gain a clearer understanding of the “costs” of suboptimal care on their bottom lines.
“If I renovate my semi-private rooms to private rooms, I may know that I’m going to have an increase in satisfaction. I’m likely going to have a reduction in hospital-associated infections. I’m going to have reduced noise level. These are all positive things, but as an organization, I may not take the time to put the dollar numbers on it,” she says.
Healthcare staff must understand how healthcare delivery is evolving as payment models change— and how these changes are affecting their workplaces and workspaces. Healthcare providers are designing their facilities to better serve patients by, for example, locating exam rooms closer to clinical work areas so physicians have easier access to their staff and needed supplies.
“Health care is changing rapidly, and if we don’t change along with it, we’re going to be left in the dust,” says Lovik-Kuhlemeier. “And that will end up affecting your business.” Whether through presentations given by change experts, articles in internal newsletters, or seminars, staff should be educated on the need to adapt and what form that may take.
Karen Wagner is a freelance healthcare writer and editor who contributes regularly to HFMA publications.
Interviewed for this article: Deborah Lovik-Kuhlemeier is clinical operations manager, UW Health Yahara Clinic, Monona, Wis. Deborah.Sandy Kamnetz, MD, is vice chair of clinical care for the Department of Family Medicine, and clinical professor, University of Wisconsin School of Medicine and Public Health, Monona, Wis. Barry Rabner is president and CEO, Princeton HealthCare System, Plainsboro, N.J. Ellen Taylor, AIA, MBA, EDAC, is director of research, The Center for Health Design, Concord, Calif.
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