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What's the Bottom Line?

By Michelle Bowles

In this era of rising costs and decreasing budgets, healthcare facilities are forced to find ways to stay competitive and increase their bottom lines — all while providing excellent patient care and attracting the best staff.

Meanwhile, hospitals also face the prospect of accommodating a multitude of baby boomers as they approach an age when they may need long-term care. “Many of today’s hospitals were built in the 1950s and aren’t adequate for the needs of the population now,” says Anjali Joseph, Ph.D., Director of Research at The Center for Health Design (CHD). As a result, new construction and renovation projects have taken off. According to the Healthcare Finance Forum, more than $33 billion will be spent on hospital construction by 2010.

Healthcare design is gaining prevalence as hospital administrators realize it can help increase the bottom line by decreasing staff turnover rates, attracting additional patients and reducing medical costs. “There’s nothing more important than design when creating facilities,” says Mike Way, Vice President of Materials Management and Facilities Services at Bronson Methodist Hospital, Kalamazoo, Mich. “It really pays off in a lot of ways.”

Organizations like the CHD and the Coalition for Health Environments Research (CHER) are paving the way for healthcare designers to communicate the benefits of design through evidence-based research. The CHD’s Pebble Project — a national partnership with healthcare facilities that are implementing evidence-based design — is proving that healthcare design can make a difference in quality of care and, in turn, overall financial performance.

“Research statistics from these organizations are really enhancing the selling points of healthcare environments,” says Linda M. Gabel, IIDA, AAHID, Senior Associate at NBBJ, Columbus, Ohio. Hospital administrators are quickly learning that healthcare design should no longer be viewed as a cost, but rather as a wise investment.

A Hospital's Lifeline

Retaining a quality staff is of utmost importance for healthcare facilities. Hospitals short on time and resources find it difficult to train and retrain employees. And in an industry focused on people, it’s essential to maintain an experienced staff familiar with the work environment and culture. “Hospitals are beginning to realize that to keep patients happy, you must keep your staff happy,” Joseph says.

Key to this happiness is making staff members feel comfortable and involved with the design process, Gabel says. By observing how staff members work and interact with one another, as well as engaging them in conversation about how design can improve their processes, designers can ensure changes will be met with a warm welcome. Staff members were involved in all stages of Bronson’s new outpatient and inpatient pavilions completed in 2000, says Jacqueline Wahl, Executive Director Support Services at Bronson, also a Pebble Project partner. “We made them feel they were a part of it,” she says.

Hospitals find themselves pressed to retain nurses, in particular. The current nursing shortage, which directly impacts patient safety and satisfaction, will only worsen as the nursing force ages. Registered nurses in the United States will average 50 years old by 2010 and have a turnover rate of 20 percent each year, according to the Joint Commission of Accreditation of Healthcare Organizations (JCAHO). Primary contributors to this turnover are poor physical working conditions and compensation, the JCAHO reports. While design can’t directly impact the latter, it can contribute significantly to improving the former.

Nurses are prone to high levels of physical and emotional stress in the workplace, but design can combat these stressors. Patient lifts are important to incorporate, as they help eliminate the strain and backaches that nurses can suffer as a result of lifting and transporting patients, Gabel says. Lifts and transferring devices can reduce back injuries by almost 50 percent, from 83 injuries per 200,000 work hours to 47 per 200,000 work hours, according to the study “Reducing Back Stress to Nursing Personnel,” by A. Garg and B. Owen.

On the emotional side, private staff areas help both nurses and doctors temporarily remove themselves from the hustle and bustle of daily work. Natural lighting and windows with views can help decrease stress levels.

“There’s a remarkable difference in staff satisfaction rates in staff break rooms with windows and without,” Gabel says.

Nurse stations at Bronson were designed to be large enough for group gatherings. “Nurses are social creatures. [Large nurse stations] make them feel like part of a team,” says Katie Harrelson, Vice President of Patient Care Services and Chief Nurse Executive.

Smart design also allows nurses to focus on their primary responsibility: the patient. In a 12-hour period, healthcare workers (not just nurses) spend only 1.1 to 3.3 hours in patient rooms; the majority of nurses’ time is spent walking between patient rooms and nursing stations, according to the 2003 “A Time and Motion Study of Health Care Workers.” But by observing nurses’ work habits, designers can reduce the number of necessary steps taken on any given day.

In a more efficient work environment, nurses can dedicate extra time to caring for their patients, “the reason they went into nursing in the first place,” Gabel says. Aside from keeping nurses satisfied with their jobs, “patients feel they are well cared for with true empathy.” At Bronson, break and conference rooms were added to each floor to reduce the number of steps taken by staff, Harrelson says. Today, “staff turnover and vacancy rates are at best-practice levels.”

But design also can assist in keeping support staff satisfied. Hospitals have a particularly difficult time retaining cleaning staff; they see an estimated 70-percent turnover rate in this area, Gabel says. Here, designers can contribute to an improved rate by using interior finishes that require less-intensive cleaning methods. With efficient cleaning processes, these staff members are more likely to be satisfied with their jobs and, in turn, stick around for the long haul.

Keeping the Client Happy

Hospitals face extreme pressure when it comes to attracting higher patient populations. Healthcare facilities compete to be internationally recognized for one specialty or another, whether it’s as the leading cancer institute or the top children’s hospital. This added competition is, in part, a result of educated consumers and decreasing government compensation. Thanks to the Internet, patients and their families can search for a hospital that best fits their needs.

To accommodate this trend, hospitals frequently give virtual tours and publish positive outcomes on their Web sites, Gabel says. “The hospitals that communicate openly and freely may gain financial ground,” she says. “It’s really an advantage to draw as many insurance companies and paying customers as possible to offset Medicare and Medicaid patients, which are not revenue generators.”

Patients are looking for well-designed hospitals that are comfortable and aesthetically pleasing. “The environment is a strong predictor of a patient’s overall satisfaction of care,” Joseph says. “The more satisfied they are with the environment, the more satisfied they are with the care.” The CHD’s Pebble Project has found that access to natural light, use of acoustic materials to reduce noise levels and private rooms all contribute to high patient satisfaction levels.

Bronson has incorporated benches and plants in hallways, large windows with views and an outdoor
atrium in order to create a soothing, healing environment. In a recent focus group report, 14 of the 15 patients interviewed said they would either return to the hospital again or recommend it to friends and family. In fact, overall admission at Bronson has increased 40 percent since the new facilities opened, Harrelson says. “We hear it from patients: They really want to experience a healing environment,” she adds.

But equally important is how satisfied a patient’s family is with the overall hospital experience. Historically, patients and families each were given their own areas and treated as separate entities. Now, as families move into patient rooms, they are treated as a single being, Gabel says. Today’s patient rooms must have ample space for family members; meditation rooms, resource centers and outdoor areas are needed to give them a place to refuel. “It’s a win-win [situation] providing choices,” she says. “And the choices don’t have to be elaborate.”

Combating Medical Costs

Patient falls, hospital-acquired infections and medical errors account for significant added costs for hospitals. But design elements that help decrease these instances can contribute to better financial performance for healthcare facilities.

Falls are particularly pricey for hospitals. Patients may be forced to prolong their stays, and hospitals may be faced with costly lawsuits, Joseph says. One way to cut down on falls is to reduce the distance from a patient’s bedside to the bathroom (where Gabel says most falls occur) by positioning beds closer to bathroom doors.

The Barbara Ann Karmanos Cancer Institute, a Pebble Project partner located in Detroit, has seen a 6-percent reduction in patient falls thanks to doorway angles that allow for better visualization of patients, enhanced lighting and improved room layouts, the CHD reports.

Proper lighting and acoustic materials help patients develop normal sleep patterns, which can reduce pain medication and length of stay, Gabel says. “The environment has to be intuitive for patient rest,” she adds. To diminish the risk of hospital-acquired illnesses, surfaces can be constructed of materials that prohibit the transfer of germs and are easily cleaned, while single-patient rooms can serve as a physical barrier to prevent the spread of disease.

Bronson — whose new facilities incorporate private rooms, strategic locations of sinks and an air inflow design — measured the rate of hospital-acquired infections two years prior to moving into the new facilities and two years after, finding an 11-percent reduction, according to the CHD. The hospital, in large part, attributes that reduction to its private rooms, Way says, and it anticipates an even lower rate in the future. “It’s much less expensive to manage a hospital with single-family rooms,” he says.

Bronson will soon take single-patient rooms one step further when it unveils a new neonatal intensive care unit. The updated facility will eliminate all multi-crib nurseries, incorporating private rooms in an effort to foster family-centered care and combat the spread of hospital-acquired illnesses. The hospital currently is measuring the “before;” it plans to measure the “after” when the facility opens, Way says.

Turning Research Into Reality

With solid evidence on how design can influence hospitals’ bottom lines, healthcare designers are equipped with an effective tool when approaching potential clients. Healthcare design now goes beyond aesthetics and faces head-on the business side of the equation. “Healthcare designers are increasingly demonstrating the value of interior design and how it relates to business and patient outcomes,” Gabel says. “Healthcare is really leading the edge in that area right now.”