The Center for Health Design Blog

Evidence-Based Design Issues

The American Society for Hospital Engineering (ASHE) of the American Hospital Association (AHA) recently published a guidance statement on evidence-based design (EBD).

This statement reflects concerns among ASHE board members and staff about potential misrepresentation of EBD and is meant to provide guidance to its members who are involved in the project development process.

While many of the points brought up in this statement are valid, there are others that need some clarification and further discussion. I’d like to start a discussion about it on this blog so we can all come to a better understanding of how we can, in our different roles, contribute to the design of safer and better hospitals.

EBD is an evolving concept and as more projects following an EBD process near completion, we are reaching a better understanding of many different issues. Some of points of concern that have been brought up in the ASHE statement are still being discussed in the field of evidence based medicine (which has been around for a long time). Building on an evidence based medicine tutorial developed by librarians at Duke University and University of North Carolina, I’d like to clarify some of the points raised in the ASHE statement and invite further discussion.

Opponents:
EBD is “old hat.” Architects and designers have been using research to guide their decisions for a long time. The label is new.

Proponents:
The new focus on EBD “formalizes” that “old hat” process and filters the literature so that decisions are made based on “strong” evidence.

Opponents:
EBD is “cook book design.” It suggests that decisions are based solely on the evidence, downplaying experience and imagination.

Proponents:
EBD should be one part of the process. Design decisions must be based on many different things — the individual architect/firm’s experience, site specific and organization specific issues, and, when available, good evidence.

Opponents:
EBD is the mindless application of general studies conducted in different types of healthcare settings and different populations to a specific building design project.

Proponents:
A key step in the EBD process is to critically analyze the evidence and decide whether or not the information and results are applicable to your project.

Opponents:
Often there is no randomized controlled trial or “gold standard” in the literature to address a particular design problem

Proponents:
The design team might consider the “evidence pyramid” and look for the next best level of evidence. Architects and designers need to understand that there may be no good evidence to support every design decision.

Opponents:
There is often great difficulty in getting access to the evidence and in conducting effective searches to identify the best evidence.

Proponents:
Resource librarians can help identify the best resources and teach design professionals effective searching skills.

What do you think? Let us know!

Redefining “Evidence-Based Design”

The beauty of words, terms and phrases in any language lies in understanding that their meanings can evolve over time as dictated by cultural and societal changes. There are many definitions of “evidence-based design” currently in circulation in the healthcare design community that focus on the use of evidence and creating hypotheses in the service of patient, family, staff outcomes.

As an organization, we feel that it is time to reconcile those different interpretations, and articulate a CHD endorsed definition that captures where our industry is today. The new definition was recently drafted in a collaborative effort by a group of 15 industry experts, including CHD Board members and staff, and can be read below. We welcome your comments.

Evidence-Based Design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. (Source: The Center for Health Design)

Healthcare Leads the Way in Energy Efficiency

Two new studies from the American Society for Healthcare Engineering and Johnson Controls in collaboration with the International Facilities Management Association offer up some interesting information on the importance of energy efficiency to U.S. healthcare executives. On average, they plan to spend 8% of their capital budgets and 6% of their operating budgets to conserve energy in the coming year. This is more than any other business sector.

Most are improving their building management systems; installing energy efficient lighting, variable speed/frequency drives, and lighting sensors; adjusting time that heating/AC runs; and negotiating energy contracts with suppliers.

Hospitals are one of the worst energy “hogs,” so this is good news indeed — and one that experts believe is a long-term trend. And while I’d like to think that part of the motivation is because healthcare organizations want to be more environmentally responsible, most of it is due to the soaring price of energy and the need to control costs.

No matter — the important thing is that healthcare is realizing that going green is not only good for the planet, it is also good business.

P.S. If you haven’t checked out the Global Health & Safety Initiative’s new website yet, please do. This is a collaborative effort between CHD, Health Care Without Harm, Practice Green Health, and a group of health systems to collect and disseminate information on worker safety, patient safety, and environmental health and safety.

Johns Hopkins Tops U.S. News’ Annual Rankings

This week, U.S. News & World Report’s annual rankings of America’s Best Hospitals hit the newsstands. Johns Hopkins Hospital in Baltimore topped the Honor Roll list (high scores in six or more specialties), followed by Mayo Clinic in Rochester, MN, Ronald Reagan UCLA Medical Center in Los Angeles, CA; Cleveland Clinic in OH; Massachusetts General Hospital in Boston, MA (a CHD Pebble Project partner); and 14 others.

The rankings are based on several factors: 1) reputational survey (random sample of 200 physicians for each of the 16 specialties); 2) mortality index (Medicare data); and information on other care related factors (mostly from the American Hospital Association’s member survey).

I’m happy to report that two of our other Pebble Project partners also ranked in the top 10 of several specialty areas: M.D. Anderson Cancer Center in Houston (pictured below) is #1 in Cancer and #4 in Ear, Nose & Throat, and #9 in Urology; St. Luke’s Episcopal Hospital also in Houston is #7 in Heart & Heart Surgery.

As I scrolled through the list looking for Pebble Project partners, I was pleased to see many hospitals whose names I recognized as being published in Healthcare Design magazine’s annual Architectural Review issue or recipients of CHD’s annual Healthcare Environment Awards. So, although facility design is not a factor in the rankings (see my blog post from July 23, 2007), many are recognizing that excellence in medical care is related to excellence in facility design.

Rare Study of Legendary Healthcare Organization

In a book just published last month, CHD board member Leonard L. Berry and Kent D. Seltman have skillfully transformed Mayo Clinic’s elite-level performance into lessons that managers in any industry can use. Management Lessons from Mayo Clinic: Inside One of the World’s Most Admired Service Organizations (McGraw-Hill, June 2008) is the first in-depth study of this notoriously “private” organization.

Len, a Distinguished Professor of Marketing Leadership in the Mays Business School at Texas A&M University, and Kent, director of marketing at Mayo Clinic from 1992-2006, spent many months studying Mayo intensively. The book is based on their numerous personal interviews with leaders, clinicians, staff, and patients, as well as observations of hundreds of clinician-patient interactions.

It was, in fact, Len’s experience studying Mayo that led him to CHD. Having spent most of his career studying, writing, and teaching about retail service organizations, he turned to healthcare as a new challenge — serving as a Visiting Scientist at Mayo Clinic in Rochester during the 2001-2002 academic term. Upon returning to College Station, he reached out to Roger Ulrich, a professor in the Texas A&M College of Architecture and long-time CHD board member. Shortly after that, we invited Len to one of our Pebble Project meetings, where he mesmerized us with stories from his Mayo experience. Since then, he has been actively involved in our organization.

And while this book is more about understanding the management culture and systems that produce Mayo Clinic’s signature service to patients and families, it does offer some interesting insights that can be applied to facility design. In Chapter 7, “Orchestrating the Clues of Quality,” the authors write about the three types of experience clues that customers process and organize into a “set of impressions that evoke feelings.” One of these types of clues — mechanics — come from inanimate objects, such as facilities, equipment, furniture, displays, lighting, and other sensory clues.

Len and Kent’s book is a gem — must reading for every healthcare executive and anyone else who is looking to achieve service excellence in their organization!

Healthcare Continues to Make a Statement at NeoCon

Used to be that healthcare was just a second thought at NeoCon — the U.S.’s largest commercial furnishings exhibition held every June at The Merchandise Mart in Chicago. But that has changed.

Make no mistake about it — NeoCon is still mostly about office furniture, with companies like Steelcase, Herman Miller, Haworth, Knoll, KI, Allsteel, and many others showcasing the latest and greatest in systems furniture, seating, casegoods, etc., as well as floorcovering, fabrics, and other accessories for today’s modern workplace.

However, in walking the show — five floors in The Mart totaling approximately 250,000 sq. ft. each — there was plenty of healthcare furniture to be found, a lot from Center for Health Design affiliate members. Many were showing prototypes that they planned to introduce at our Healthcare Design conference in the fall, and many were offering “tweaks” to already successful products. As always, maintenance and cleanability were common themes, as well as attention to sustainability, choice/control, and improved aesthetics. A few standouts included:

Nurture by Steelcase’s brand new showroom on the third floor was hopping. Most interesting was Sonata, a system of workstations/storage/dividers that offers an innovative answer to oncology infusion bays that focuses on the place where all “three” users — patient, caregiver, family/friends come together to spend many hours during the course of patient treatment. Sonata won a well-deserved Gold Award in this year’s Best of NeoCon product design competition.

Herman Miller for Healthcare’s Nala high-performance patient chair also won a Silver Best of NeoCon award. This futuristic really comfortable chair features a permeable seat and back suspension and 10-degree recline to reduce spinal stress and disperse body pressure. A three-degree forward tilt enables entering and exiting the chair with the use of a manual shift control mechanism.

KI introduced the Arissa Collection, a group of bariatric seating. What is unique about Arrisa is that is actually universal — blending form and scale through unique shapes and carefully crafted geometry that allow virtually any user, regardless of size, to sit comfortably. You look at this chair and you don’t think bariatric.

Lots of manufacturers have added heating components to their oncology chairs, but Nemschoff went one step further and also put a massage mechanism in its nicely scaled Serenity 3 chair.

Other notable exhibitors/showrooms: Lees Carpets (part of The Mohawk Group), Tandus Group, Spec Furniture, Wieland, and Interface (where Chairman Ray Anderson showed us his latest ideas for green product manufacturing).

I can’t wait to see what all these companies introduce/show at Healthcare Design conference in the fall!

Sobering Facts About MRSA Epidemic

I just read a fascinating article in this month’s issue of Hospitals & Healthcare Networks about the MRSA epidemic, which most experts agree is real. You can read the entire article, but I’ll summarize some of the facts here.

MRSA is a type of staph bacteria that is resistant to common antibiotics. It also seems that staph bacteria, including MRSA, are common causes of skin infections in the U.S., as well as pneumonia, surgical wound infections, and bloodstream infections.

The three leading causes of antibiotic resistance are excessive and unnecessary antibiotic use in humans; excessive antibiotics in cattle, pigs, and chickens, as well as feedlot runoff into streams and groundwater; and bacteria’s ability to adapt and resist antibiotics faster than new ones can be invented.

According to the Association for Professionals in Infection Control and Epidemiology, as many as 5 percent of hospital and nursing home patients in the U.S. today may be infected or colonized with MRSA bacteria, which is 10 times higher than previously thought.

MRSA is spread almost exclusively by touch. That means people touching each other, touching contaminated objects, or eating food handled by an infected person.

It follows then, that reducing MRSA starts by having clean hands. Hospitals are aggressively promoting this by hanging posters and other reminders in staff rooms, corridors, and patient rooms; keeping soap and gel dispensers full; putting sinks next to beds; using design elements, such as lighting or color coding to highlight those sinks; and advising patients to always ask their caregivers whether they have washed their hands.

EBD is Not ‘Medical Feng Shui’

Yesterday, Maureen Larkin posted an article for HealthLeaders Media Quality Leaders e-newsletter on Emory Hospital’s new ICU titled “Medical Feng Shui.” She opened her article with these words: “We’ve all seen the designers on the home improvement networks talking about the design and flow of a home and how it can effect a person’s energy. Turns out that feng shui is a valid concept in healthcare, too. We just call it evidence-based design.”

Now perhaps Ms. Larkin thought she had come up with a compelling lead to her article, but I respectfully have to disagree with her interpretation. Comparing evidence-based design (EBD) to feng shui is like comparing apples to oranges. They may both look at how the design of the built environment affects behavior, but EBD is based on solid, scientific evidence — more than 1,500 studies and growing every day — that document the built environment’s impact on outcomes. Feng shui has no such scientific rigor behind it.

I’m not saying that there isn’t something to the ancient Chinese art of placement, but feng shui isn’t even in the same league as evidence-based design. According to researchers Roger Ulrich, Ph.D., and Craig Zimring, Ph.D., the 1,500 studies show clear links between the built environment and patient outcomes, including safety issues like infections, medical errors, falls and injuries, confidentiality and privacy, and also other outcomes such as stress, sleep, spatial orientation, pain, depression, social support, communication, length of stay, and satisfaction.

They also link building design to staff outcomes, such as stress, safety, effectiveness and efficiency, and satisfaction. In addition, there are clear financial implications to many of these outcomes, which can affect operational performance.

Ulrich and Zimring’s latest review of the evidence-based design literature (a project funded by the Robert Wood Johnson Foundation in association with the Georgia Institute of Technology and The Center for Health Design) is being published in the Spring 2008 issue of the HERD journal, which is coming out this week.

Medical Tourism — A Passing Fad or New Reality?

As reported in Modern Healthcare recently, a study conducted by the Deloitte Center for Health Solutions found that U.S. healthcare providers will lose almost $16 billion in 2008 to those seeking treatment abroad.

Granted, that’s only about 3% of total U.S. hospital revenue right now, but that figure is expected to grow to $68 billion by 2010.

Why wouldn’t you go abroad for a hernia repair if it would cost $1,800 instead of $5,400? Or get knee repair surgery for $1,400 instead of $12,000? Increasing costs of healthcare, higher deductible health plans, and increasing co-payment rates are making it a more attractive option for many. Not to mention that you can build in a little vacation time while you’re at it — that’s why it’s called medical “tourism”.

And foreign hospitals are improving their quality standards as well. Many are becoming Joint Commission accredited and hiring physicians that are trained in the U.S. Yet questions about continuity of care and liability still loom. Some feel that U.S. hospitals won’t really be affected by medical tourism unless insurers begin to cover care received abroad.

What’s more, although foreign hospital construction statistics are hard to come by, the drive to improve quality standards and increase market share has to be creating a demand for new and improved facilities. At The Center, we’ve seen increased interest from abroad in our work in the past two years.

So, while we still have a lot of work to do here right at home, the message here is, there are opportunities abroad to design safer, more supportive, and healthier hospitals abroad as well.