Competing by design: healing environments attract patients, reduce costs and help recruit staff. (Innovation).

TAKE A LOOK AT YOUR hospital or medical office.

If you think of a hospital as an antiseptic environment with harsh lighting, stiff furniture and views of acoustical tile ceilings from a drab sickbed, think again. (1) Picture a medical clinic painted in the warm colors of Tuscany, with a Renaissance-style mural of the daughters of Aesclepius on the walls and a fluffy robe for every patient.

A fresh wave of health facilities are coming that promise to reinvent the concept of a hospital and revive the spirit of "hospitality" in patient care settings. Health care architects and designers are updating and upgrading hospitals with new facilities like:

* Bronson Medical Center in Kalamazoo, Mich.

* Doernbecher Children's Hospital in Portland, Ore.

* Northwestern Memorial in Chicago, Ill.

* Woodwinds in St. Paul, Minn.

* Griffin Hospital in Stamford, Conn.

* Children's Hospital and Health Center in San Diego, Calif.

The emphasis on healing design in these new facilities is long overdue recognition that patients' surroundings affect their well-being.

Lighting the way

Health care architects, space planners, interior designers and progressive industry suppliers are developing innovative concepts for health facilities, including:

* Natural light that penetrates interiors

* Open space in atriums, walkways

* Noise reduction and elimination of overhead paging

* Patient privacy and control of their environment

* Healing gardens

* Theraputic art and sculpture

* Private (one-patient) oversized rooms

* Hidden storage of supplies and equipment

* Views of the natural environment

* "Village"-like campuses of ambulatory, inpatient facilities

* Integrated physician offices

* Environmentally friendly "green" design

* Cafes, bookstores and health-related retail shops

* Wellness, fitness and complementary medicine

* Digital and wireless telecommunications

* Internet access

The best of these new facilities are focused on evidence-based design. Like evidence-based medicine, the goal is to translate research findings on the impact of the environment on patients' physical and psychological health.

More than 125 research projects have been conducted in the U.S. and around the world testing the health care designers' palette of color, light, noise control, art, privacy, space and scale.

The goal of research in healing design is to create health facilities that reduce patient stress, utilize fewer strong medications and promote rapid recovery.

Some of these new hospitals are formally evaluating the fiscal, clinical, behavioral and health status impacts of health care design in a collaborative research model pioneered by the Boston-based Institute for Healthcare Improvement.

In the past, hospitals that experimented with radical new designs seldom knew if the new ideas actually worked. The Center for Health Design, based in Lafayette, Calif., is recruiting a consortium of hospitals that is building new health facilities utilizing principles of healing design.

These institutions are committed to research and evaluation to see how well their new facilities work in practice. They're looking at cost of operation, patient and family satisfaction, staff morale, use of resources such as pharmaceuticals, labor hours and health status outcome.

Understanding the environment

Researchers are developing a new understanding of how the environment affects patients.

Studies are testing the way in which health care surroundings interrelate with medical care, illness and patient attributes. This new field of environmental psychology is called "psychoneuroimmunology," focusing on the correlation between stress and health. (2)

The findings demonstrate that the mind, brain and nervous system can be directly influenced, positively or negatively, by sensual elements in the environment. The research surprised many designers.

Health care interiors must be stimulating, not neutral. Normal consciousness can be maintained only in a constantly changing environment. The drab interiors and unchanging artificial light typically found in many hospitals may dull the senses and be visually and emotionally stressful.

There are three primary ways in which the environment can influence patients' outcomes: (3)

1. Medical care--The environment can support or hinder caregiver actions and medical interventions, making it easier or more difficult for clinicians to do their jobs and facilitating helpful or harmful impacts. One example: carpeting reduces the stressful hubbub and noise of health care workers moving about in the patient's room.

2. Health status--The environment may strengthen or impair patients' health status and personal characteristics by alleviating or exacerbating existing conditions and patients' personal strengths. One example is that loss of sleep due to noise in the post-operative setting may prolong recovery time.

3. Causes of illness--The environment can protect patients from or expose them to causes of illness. Circulation of ultra-clean air may protect hospitalized patients from debilitating or even fatal nosocomial infections.

And the research shows

Research on the impact of the environment on patients links poor design to negative outcomes such as anxiety, delirium, elevated blood pressure and increased use of pain drugs. (4)

A landmark study in the early 1980s found that 23 post-surgical patients in rooms with views of a stand of trees stayed for fewer post-operative days, received fewer negative evaluative comments in nurses' notes and required fewer potent analgesics than 23 matched patients in similar rooms with windows facing a brick wall. (5)

Dozens of other studies have sought to evaluate the healing impacts of factors such as room size and scale, privacy, environmental control by the patient, lighting, color of walls and furnishings, patterns in walls and fabrics, air and ventilation, art, music, windows, views and the relationship with nature.

In 1998, researchers at the Johns Hopkins University prepared a comprehensive review of 84 studies involving the impact of the health care environment on patient outcomes.

Hopkins researchers scanned nearly 80,000 articles in the National Library of Medicine to identify a body of research that demonstrated one or more impacts of the built environment on patient outcomes and satisfaction.

Although results from these early studies are promising, the Hopkins scientists cautioned that the body of evaluated research on health care design is limited and it is difficult to isolate and change only one feature of a health care environment while controlling all other factors.

Boosting revenues, cutting costs

Advocates of healing design believe patient-centered, therapeutic facilities will be magnets for consumers.

Baby boomers respond very positively to facilities like Planetree's Griffin Hospital in Connecticutt, Northwestern Memorial in Chicago and HealthEast's new Woodwinds Hospital, located on a 25-acre park-like setting with woods and a pond.

These facilities offer greater privacy, views of nature, lots of education and communication and even massage. The result is higher patient satisfaction, market ratings and revenues, as patients drive across town past conventional hospitals to get to these award-winning facilities.

Healing design is a magnet for staff, too.

When Woodwinds recruited for 400 new positions to staff its award-winning facility, it received 3,800 resumes.

On the other side of the balance sheet, healing design may reduce expenses. Key cost-cuffing impacts of healing designs include:

* Shorter lengths of stay

* Lower costs per case

* Reduced use of stronger drugs

* Fewer negative notes in nursing progress reports

* Reduced nurse hours per patient

* Improved staff morale

* Reduced turnover and costs for recruitment

The bottom line is happier patients who use fewer strong medications, are easier to care for, go home sooner, love their hospital and recommend it to others.

Ten years ago, architect Derek Parker, senior principal of Anshen + Allen in San Francisco, estimated the cost savings from better buildings with shorter stays, drug savings and labor costs at $10 million a year for a 300-bed hospital. (6)

Staffing alone would pay for the increased costs to build and operate a healing environment. Parker estimated the cost of recruiting a nurse at $20,000 in 1991. A decade later the average nurse costs between $72,000$87,000 year, or $42 to $50 per hour. (7)

Assuming 4.7 full-time equivalent staffers per adjusted occupied day, just nursing hours and benefits can quickly reach $1,200 per patient per day or higher. Parker's $10 million estimate of the annual impact of a better building could be $15-$20 million in today's dollars.

Blair Sadler, CEO, Children's Hospital and Health Center in San Diego believes that the lesson for all health care organizations is clear: provide an environment that is welcoming to patients, improves their quality of life and supports families and employees--or suffer the economic consequences in a competitive environment.

In the past 10 years, Children's boosted its market share almost 15 points, drove its major competitor out of the pediatric business and boosted philanthropy from $6 million to $14 million per year.

Competing by design works!.

Summary of Johns Hopkins University Research on the Impact of Health
Care Environment on Patient Outcomes (3)

Environmental factor                Scope of research

Amount, layout and decor of spaces  Psychiatric, substance abuse
                                    treatment patients

Bedside computers                   Geriatric medical-surgical
                                    patients

Bed enclosures                      Burn patients

Exposure to natural sunlight        Elderly, geriatric patients

Furniture placement                 Psychiatric, rehabilitation
                                    patients

Intensity of artificial lighting    Several categories of patients

Humidity                            Premature infants

Natural window views                Cholecystectomy, post-surgical
                                    ICU, neonates

Newly-built vs. refurbished ward    Geriatric patients

Noise levels                        Intensive care, postoperative
                                    patients

Placement of ultraviolet lights     Premature infants

Privacy/openness of room or ward    Acute medical, cataract
patients                            surgery

Room carpeting                      Elderly patients

Room exposure to sunlight           Depressed patients

Tapes of music, sound simulation    Heart surgery, gyn surgery,
                                    emergency lacerations,
                                    arthroscopic surgery, dental
                                    surgery, and newborns

Temperature                         Premature infants

Temperature of respired air         Mechanically ventilated
                                    patients

Type of ambient music               Psychiatric patients

Ventilation system contaminants     Intensive care, ambulatory
                                    surgery, leukemia, and bone
                                    marrow transplanation
                                    patients

References:

(1.) Mack, L. "New Woodbury Hospital Uses Natural Ambience to Assist the Healing Process; Woodwinds Is an Example of Push to Make Facilities Patient-Friendly." Minneapolis Star-Tribune newspaper. July 30, 2001.

(2.) Gappell, M. "Psychoneuroimmunology." Innovations in Health care Design. Van Nostrand Reinhold, New York, 1991.

(3.) Rubin, HR, Owens, AJ, and Golden, G. An Investigation to Determine Whether the Built Environment Affects Patients' Medical Outcomes. Center for Health Design, Lafayette, Calif. 1998.

(4.) Ulrich, R. "Effects of Healthcare Interior Design on Wellness: Theory and Recent Scientific Research." Innovations in Healthcare Design. Marberry, S.O., ed., Van Nostrand Reinhold, New York, 1995.

(5.) Ulrich, R. "View Through a Window May Influence Recovery From Surgery." Science. April 27, 1984, (4647) 224, 420-421.

(6.) Parker, D. "A Better Buildings Benefits." Modern Healthcare. Dec. 9, 1991, 21(47): 30.

(7.) O'Neill, D. "Update on Parker Estimates." Personal communication with the author. Aug. 1, 2001.

Russell C. Caule, Jr. is the editor of Russ Coile's Health Trends, a monthly newsletter now in its 14th year, where his trends predictions for the past 10 years have been 90 percent accurate. He has authored 10 books on the future of health care, including Paperless Hospitals (2002), New Century Health care (2000) and The New Medicine (1990). To contact him in Washington, TX, call 936-878-9986, or e-mail [e-mail].