The Center for Health Design Blog

Can Hospital Buildings Heal?

I read the statement today, “hospital buildings can heal,” and something about it struck me as wrong. “Hospital buildings can heal” implies that there are no other factors in healing, such as treatment methods, physician expertise, or caregiver support.

My computer dictionary defines “heal” as 1. to make a person or injury healthy or whole 2. to be repaired or restored naturally, for example, by the formation of scar tissue 3. to repair or rectify something that causes discord and animosity 4. to get rid of a wrong, evil, or painful affliction.

In the context of what we are talking about here, the #1 definition makes the most sense. So, can hospital buildings make a person or injury healthy or whole? Of course not. But we do know that the design of the physical environment can positively affect patient and staff outcomes, thereby improving the quality and safety of healthcare delivery.

Hospital buildings cannot heal, but they can affect the healing process. We are way past the place where they were just viewed as bricks and mortar to house what goes on within. Florence Nightingale was one of the first in healthcare to recognize this. Hospital buildings are part of an integrated system of people, technology, and culture that delivers care and helps people to heal.

Healing Environment or Healthy Environment?

I was looking at the brochure for the CleanMed conference today, which is next month in Pittsburgh. The tag line for the conference this year is “Creating Healing Environments.”

I find it interesting that the conference organizers have used the term “healing environments” to describe environmentally sustainable practices for healthcare. Our definition of healing environments (developed by healthcare designer Jain Malkin more than 10 years ago) is:

“A healing environment is a physical setting that supports patients and families through stress imposed by illness, hospitalization, medical visits, recovery, and sometimes, bereavement.”

Wouldn’t it make more sense to call an environmentally responsible environment a “healthy environment”? Do sustainable practices actually foster healing or health? I guess you could say that sustainable practices can help reduce stress for patients, families, and staff, but a healing environment is much more than just an environmentally responsible one.

In fact, design interventions to create healing environments can be linked to the Institute of Medicine’s six specific aims for improvement that were outlined in its 2001 report: safe, effective, patient-centered, timely, efficient, and equitable. I would argue that environmental sustainability belongs in the “efficient” and “safe” categories.

Using “creating healing environments” to describe the CleanMed conference muddies the waters for those who are trying to understand the concept. Clearly, it is much bigger than just sustainability and hopefully this will be explained by the presentors at the conference.

News Flash: Healthcare Building Boom Slowing Down

Did we really think this would go on forever? The latest stats coming out of Modern Healthcare’s annual Construction & Design survey, as well as data from the American Society for Healthcare Engineering and Reed Construction Data/RSMeans indicate that the industry is still in a “major construction mode,” but that a slowdown is expected after 2010.

Is this news to any of us? Construction booms come and go, but the reality is that in healthcare, the factors affecting the need for new or renovated facilities are not going away in the near future. These include obsolete/aging facilities, technological advancements that affect how care is delivered, and the aging of the baby boom generation.

Urban sprawl and as well as the reverse in some areas, where new condos, town homes, apartments are attracting empty nesters back to the city, are also creating a demand for new healthcare services and facilities.

The pace of building is not going to continue at the growth rates of the past few years, but there is still plenty of building going on. Modern Healthcare reports that 2,561 projects were started last year with a projected cost of $38.4 billion and 3,920 projects were in the design phase with a projected cost of $72.2 billion. True, these numbers are slightly lower than the same measures in 2006, which is why some experts are raising the caution flag — as they should.

Quality, safety, environmental responsibility are “social movements” that are sweeping across healthcare — and we are far from solving all the problems. As long as we continue to make the case that facility design can contribute to improvements in each of these areas, the need for new construction will not diminish. Maybe slow down, but not diminish.

Who Really Pays for Medical Errors?

As we all know, medical errors cost the health system billions of dollars a year. Patient safety advocates have long sought to demonstrate that if healthcare organizations invest in safer practices and systems, they will reap financial returns in the form of reduced malpractice costs and other expenses. Our part of that conversation has been to demonstrate that the design of the physical environment also impacts those practices and systems.

But, as reported by the Commonwealth Fund, Harvard University researcher Michelle M. Mello, Ph.D., J.D., and her colleagues believe that hospitals may lack the financial incentives needed to improve safety. In their article, “Who Pays for Medical Errors? An Analysis of Adverse Event Costs, the Medical Liability System, and Incentives for Patient Safety Improvement” (Journal of Empirical Legal Studies), they found that most of the costs resulting from medical errors are actually shifted to outside parties–often to payers like Medicare.

Mello and colleagues compared the costs associated with adverse events that were absorbed by hospitals, including malpractice insurance premiums and extra inpatient care they were unable to recoup, against costs that were passed along to other payers. On average, the hospitals they studied externalized 78 percent of the costs of all injuries and 70 percent of the costs of negligent injuries.

According to the authors, changes in provider payment policy and legal reforms to allow more injured parties to pursue compensation could bolster incentives for hospitals to improve safety. This is good news, but I’d venture to guess that improving safety is in the top three priorities of most hospitals — it makes good business sense for reasons other than who ultimately pays for negligent injuries. Who would want to come to a hospital if it had a lousy safety record? Besides, it’s not morally or socially responsible.

Investing in safety improvement is not an option, it is an imperative. And design of the physical environment is an important piece of the puzzle that makes practices and systems work.

I Want One of These

If you’re like me, you sit at a desk most of the day when you’re in your office, talking on the phone, answering e-mails, and working on the computer. I usually exercise in the early morning, but often, by mid-afternoon, I’m feeling pretty sedentary.

My friend Judy also works from home, but has recently eschewed her desk in favor of standing at her kitchen counter working on her computer. “I don’t like to sit all day,” she tells me.

Well, sedentary workers, take heart! Steelcase has come up with the Walkstation, a height-adjustable workstation with an integrated treadmill. This innovative product is the result of an alliance between Steelcase and James Levine, MD, PhD, of the renowned Mayo Clinic in Rochester, Minnesota. Designed primarily for corporate work environments, the Walkstation combines Steelcase’s knowledge of ergonomics and workplace design with Dr. Levine’s research on non-exercise activity thermogenesis (N.E.A.T™) – the energy expended during everyday activity.

Dr. Levine’s proprietary N.E.A.T. research suggests that increased physical activity among sedentary workers may benefit the workplace environment and increase the overall health, focus and productivity of a workforce that is typically desk-based. Designed to encourage more movement by walking slowly at work, Dr. Levine estimates that users of the Walkstation have the potential to increase energy expenditure by 100 calories per hour when walking at a 1 mph rate. Thus, if obese individuals were to replace time spent sitting at the computer with 2-3 hours per day of walking computer time, and if other components of energy balance were constant, actual weight loss may result.

“The Walkstation is not intended to provide a gym-style workout in the office; its purpose is not to cause users to raise their heart rates or work up a sweat,” Dr. Levine says. “For office workers, the majority of the workday is spent sitting in front of a computer. The premise of this Walkstation is simply to increase movement while working, and for users to enjoy the health benefits of that movement.”

What a great idea. Priced at $3,500-$6,000, the Walkstation is intended for the corporate marketplace, but who’s to say it wouldn’t be appropriate for those healthcare workers whose primary work is office work? What’s more, healthcare organizations could really make a statement about promoting healthy lifestyles by embracing this product. Maybe insurance companies would offer premium discounts for those organizations that purchase Walkstations for their employees.

The patents pending Walkstation is the first in a series of office furniture products developed by Details (a unit of Steelcase) in collaboration with Dr. Levine. I look forward to more good stuff from them.

For more information on the Walkstation, go to http://www.steelcase.com/na/walkstation_products.aspx?f=30670.

Technology’s Impact on Green Buildings

Okay, I’ve been negligent about blogging lately. But 2008 has started with a bang and I’m scrambling to keep up with everything….

A few weeks ago, our conference planning team was having a telephone call to discuss our new Clicks & Bricks conference — which was originally scheduled for May 2008, but has now been moved to June 2009 (more info on this to come!). The idea for this two-day event is to explore the issues of technology and building design and help healthcare executives anticipate and plan for the future.

One of the interactive discussion tracks is green design and technology. At first, I was having trouble making the connection between the two, but when we started talking about how almost every aspect of green design and operations involves technology, it suddenly “clicked” for me. Here are some examples:

–The automatic faucets and toilet flushers (which never seem to work for me) that save water came about because of technology.
–Energy-efficient HVAC systems and trash to energy systems wouldn’t be possible without technology.
–Eco-sensitive products and materials engineered and fabricated using new technology.

What’s even more exciting are the new innovations ahead for green products that are being driven by nanotechnology. Green Guru Penny Bonda recently wrote a fascinating article on this subject for Interior Design LiveWire that explains it much better than I can.

Zagat Guide to Doctor’s Offices

Hey, you had to know that this was coming. Zagat, which publishes the pocket-sized burgundy-colored restaurant review guidebooks, is partnering with WellPoint to do an online survey that will allow patients to rate their doctors. How they feel about their doctor’s office environment will be queried, as well as things like trust, communication, and availability.

Zagat’s logo, which proclaims “Eat, Drink, Stay, Play,” will have to be changed to “Eat, Drink, Stay, Play, Heal.” Is the next step for them a survey of how patients rate hospitals based on the same criteria? Might not be a bad idea.

As I wrote about on this blog back in July, about 15 years ago, The Center’s president and I went to Washington, D.C., to visit the editors of U.S. News & World Report to talk to them about their annual “Best Hospitals” survey. We told them about our work and asked them why they didn’t include the quality of the built environment in their ratings. They agreed that it would make sense, but explained to us that their ratings are based on data that is already available, with the exception of the survey they send to physicians to rate hospitals based on their reputation for excellence.

They told us that if we brought them the data, they would include it. Well, that started us down the path of finding out how much evidence-based design research there was out there for healthcare (a path which we are still on today) and establishing a research agenda for the industry. But we never collected any raw data on patients (or physician’s) perceptions of the built environment of the hospitals they like.

As far as I know, no one has done this in any kind of meaningful depth. Press Ganey and Arbor may include a few questions about it on some of their surveys, but not enough to be conclusive. So, Zagat, here’s your opportunity! All you need is a partner…

Bringing Hospitality into Healthcare

Recently, I read an article in one of the industry trade magazines about a hospital in Michigan that had hired a manager from the Ritz Carleton Hotel chain. The article was touting the introduction of hotel-like amenities in hospitals — things like providing concierge service, valet parking, room service food ordering, lotions and shampoo, etc.

Healthcare can actually learn a lot from other service industries, such as hospitality, restaurant, and retail. And, in fact, it is. This trend toward providing hotel-like amenities has been happening for the past 5-10 years. The good news is that while some of these amenities were once only reserved for VIP patients, many hospitals are starting to offer extra services to all patients.

I think this is great, yet, I get uncomfortable when people start taking about designing hospitals to look like hotels. Sometimes called “hospitality healthcare design,” there are elements of hotel design that are appropriate for healthcare lobbies and even patient units. But people go to hospitals for very different reasons than they go to hotels. A hospital still has to perform certain functions, many of which involve treatments that require sterile or clean environments or highly technical equipment. Making the healthcare environment as stress-free and safe as possible should be the goal, not to make it look like a hotel.

Service, on the other hand, is different. There is no reason why hospital workers can’t provide the same level of service as hospitality, restaurant, and retail workers are taught to do. In fact, as healthcare becomes more consumer oriented, I think service will become more and more of a factor in making choices.

Leonard Berry, one of CHD’s board directors, and a marketing professor at Texas A&M, has written numerous articles on the service aspect of healthcare. Dr. Berry, who is considered to be one of the “service marketing gurus” in America, spent most of his career studying other service industries (airlines, restaurants, retail, banking), but became interested in healthcare several years ago after spending six months doing field work at the Mayo Clinic. If you’re interested in this subject, I strongly recommend that you read some of his articles.

Testing Center Gets Funding

It was announced last week that the state of South Carolina has funded the development of a Center of Economic Excellence in Health Facilities Design and Testing. The project is a collaboration among Clemson University, the Medical University of South Carolina (MUSC) and the University of South Carolina (USC), with Spartanburg Regional Health System (SRHS), and Health Sciences South Carolina (HSSC).

The purpose of the testing center is to conduct design-research projects using experts from a variety of disciplines — from architecture and psychology to materials sciences and computer science at Clemson, along with clinical researchers at MUSC and indoor environmental health researchers at USC.

The project is the brainchild of David J. Allison, a Clemson architecture professor and director of the project, who is also a member of The Center for Health Design’s Research Advisory Council.

He envisions the testing center and its labs as a destination for researchers and designers from across the country — and internationally — who will collaborate with researchers in the state and use the facilities for design-research projects, much the way astronomers visit observatories to conduct their research. The labs will provide a platform for collaborative educational, research and public-service initiatives that will help advance the state of-the-art in healthcare design.

The idea is for researchers to design, fabricate and evaluate prototype patient care and treatment settings. Feedback from simulation testing of prototypes in the laboratory will be used to revise initial designs. Revised prototypes then will be evaluated in working clinical settings within HSSC member hospitals in the state. Final prototypes and design concepts will be incorporated into new facilities built throughout South Carolina and across the country.

This is exciting news for Clemson and its program and will provide a valuable resource for our industry.

Read more about the project.

When Do We Think?

First of all, I want you to know that this photo is not of my office. I’m not going to tell you whose it is, but when I saw it, I had a good laugh, and then I realized that many of us have offices that look like this — and if we don’t, we’re just hiding the stacks of unread papers, magazines, and reports that we just don’t have time to get to.

How did this happen? Well, I’m sure it’s because of all the new information sources that have cropped up in the last decade. Who can keep up with it all? Not only can we subscribe to print magazines and journals, but now we can subscribe to weekly and daily e-newsletters, sign up for RSS feeds to tap into our favorite blogs, watch videos on YouTube, not to mention the hundreds of e-mails we all receive daily from our colleagues, companies/organizations we do business with, spammers, etc.

Last week, the Wall St. Journal reported (”Email’s Friendly Fire,” 11.27.07) that the amount of time people spend answering e-mails at work is expected to grow to 41% by 2009. Almost everyone I know struggles with this; and although e-mail is an effective communication tool, it has become a burden for many.

What did we do with all that time before e-mail? Did we talk to people on the phone? Did we read more? Did we have more face-to-face meetings or conversations? Did we have more time to think? Or, maybe we had more “down” time to free our minds to think.

It’s a delicate balance we’re all trying to juggle. I would write more, but I have to go answer my e-mails…