Hospitals are one of the most expensive commercial structures to build, with median construction costs for mid- and large-sized facilities hovering at around $300 per square foot. As a result, these high-priced construction projects must be undertaken with both the present and the future in mind.
Before green lighting a project, hospital executives must confirm that new construction will address existing pressures, as well as attract and serve patients for decades to come. With that in mind, to what extent should evidence-based design and sustainability features factor into hospitals' new building plans?
As Sheila Bosch, director of research in the healthcare sector at planning and design firm Gresham, Smith and Partners, sees it, most health systems these days expect their design firms to have experience in both areas. While hospitals may at one time have considered sustainability features like green roofs to be too costly an upfront investment, they now see the advantages such designs offer. One example is the thermal performance of the roof system, "to reduce the cost of facility operations," she said, not to mention improving patient views. "And there is an extreme need amid healthcare reform to reduce costs and improve the patient experience," given the impact the Affordable Care Act is expected to have on hospital reimbursements.
Constructing facilities with an eye toward evidence-based design should also help lower the cost of care and improve its quality. The Centers for Medicare & Medicaid Services is figuring patient satisfaction scores into reimbursement metrics, and won't – for example – compensate institutions for care delivered to a patient who sustains an injury in a fall on-premises, or to patients who acquire certain infections while in the facility. One example of how smart design may contribute to meeting some of these challenges can be found in a replacement hospital that Gresham, Smith and Partners designed. The facility includes "grab bars" on the wall leading from the bed to the toilet, and has seen an 80 percent reduction in falls after opening the replacement facility.
"I can't say for sure that the reduction in falls was solely because of the design," said Bosch. Factors such as individual patients' conditions and medication prescriptions also can influence results. But, "we know that the built environment matters. Now we just need to strengthen our knowledge base with additional rigorous, empirical research to better quantify the relationship between the built environment and the quality and safety of the care we provide."
Building the knowledge base
Studies pointing to the value of evidence-based design go back at least as far as 1984, with the publication of "View Through A Window May Influence Recovery From Surgery," which demonstrated that patients who had rooms with natural views had shorter postoperative hospital stays and slightly lower scores for minor postsurgical complications than those who had wall views. But, says Bosch, "we need much more rigorous research to inform specific design recommendations."
It's important to take the scientific evidence embedded in academic literature, the quality and safety data that exist in facility records, and the information held by staff and patients, and make it all more readily accessible to design professionals, facility managers, and healthcare leaders, said Rana Zadeh, co-director of Cornell's HealthDesign Innovations Lab. Zadeh is one of the authors of a study the Lab has underway, "An Economic Analysis of Healthcare Design Evidence-based Interventions," that will provide a practical framework to explain evidence-based design interventions and their related outcomes in financial terms.
The study's aim is "to contribute to transparent and informed decision-making about up-front capital investment in healthcare facilities. Evidence-based design, and related research, contains invaluable information that was traditionally hidden and not accessible to healthcare decision-makers." Providing this information in financial terms, to effectively communicate both costs and benefits to these parties, will help them to invest smarter by incorporating the latest evidence.
"In the near future, EBD will become an inseparable part of capital investment decision-making in healthcare facilities as it contributes to safety, liability, quality, and economic success," Zadeh said, with outcomes that range from improving staff retention, satisfaction, and performance, to reducing falls, infections, and errors, and increasing efficiency and usability.
Prepping for the long-term
Examining design and construction teams' proposed solutions in light of evidence-based design principals is important prior to beginning a construction project. In fact, it's just as important as continuously evaluating and improving the components of the healthcare environment in line with EBD goals in order to keep a facility cost-efficient and relevant into the future.
"As designers of buildings with a 40-year lifespan, or a renovation cycle of every 15 years, we have to use evidence-based design to plan for that," said Rosalyn Cama, president and principal interior designer at professional design firm CAMA, Inc. and board of directors chair at The Center for Health Design. "The economic model has to go over the lifecycle of the investment."
A hospital being planned today, for instance, should be designed to accommodate the senior citizen of tomorrow, in terms of their expectations around sustainable living and services delivery. It may be a little more expensive to make some forward-looking design changes – including embracing technology – that may matter to the patient of the future, but it's a must. "As these populations become more sophisticated and their expectations rise, you can't operate under old models anymore," Cama said.
Hospitals are thinking increasingly about these challenges and opportunities, she said. "I am intrigued with how many hospitals have developed innovation departments," said Cama. "From our perspective, evidence-based design is about improving the human experience in a complex building type."