DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE The Quality Colloquium Harvard University August 21, 2007 Blair L.

Transcript DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE The Quality Colloquium Harvard University August 21, 2007 Blair L.

DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE The Quality Colloquium Harvard University August 21, 2007

Blair L. Sadler, J.D. Former President & CEO Rady Children’s Hospital, San Diego, California Senior Fellow, Inst. For Healthcare Improvement Vice Chair, Center for Health Design © 2007 The Center for Health Design ®

Today’s Learning Objectives

 Learn about published articles on evidence-based design that correlate with improved clinical outcomes, patient satisfaction and staff recruitment and retention.

 Understand the compelling business case (capital costs vs. operating savings and increased revenue) for building optimal hospitals.  Understand a continuum of changes that you can make to improve care © 2007 The Center for Health Design ®

Institute of Medicine

- 1999

“…Serious and widespread quality problems exist throughout American Medicine. These problems…occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for service systems of care.

Very large numbers of Americans are harmed as a result…”

Institute for Healthcare Improvement, 2001

Facts

The patient safety problem is large.

It (usually) isn’t the fault of healthcare workers.

Most patient injuries are due to system failures.

Institute for Healthcare Improvement, 2001

Risks

Medical errors:

Harm more than 1.5M year in U.S.

Institute of Medicine, 2006

Hospital-acquired infections:

2M a year in U.S.; 92,000 die Modern Healthcare, 2006

Nursing turnover:

20% per year JCAHO, 2002

Healthcare Workers

75%

feel the quality of nursing care at their organization has declined in the past two years.

50%

feel exhausted & discouraged when they leave work.

40%

feel powerless to effect change necessary for safe, quality patient care.

Connecticut Nurses’ Association

Components of Quality

PATIENT CENTERED TIMELY EFFICIENT EQUITABLE QUALITY EFFECTIVE SAFE

Components of Quality

Making a Key Connection

Most healthcare environments are more stressful & riskier for patients, family members, & staff than they should be.

They actually make these problems worse!

Levels of Transformational Change

Six Domains of Quality

Safe Effective Efficient Patient Centered Timely Equitable Patient Microsystems Organization Environment Aims Promises Results People Processes Information IT Human Resources Finance Leadership Funding Community r Government © 2007 The Center for Health Design ®

Big Issues in the Next Ten Years of Improvement    The interactions between patients and the system of care The organization context of care The environmental context of care 1 st Donald M. Berwick, MD, MPP Institute for Healthcare Improvement Annual Forum for Improving Children’s Health Care March 12, 2002 © 2007 The Center for Health Design ®

“In service industries, the environment is the most objective and visible sign of respect for the patient, family and

staff

.”

Leonard L. Berry Author, Discovering The Soul of Service

“Although the premise that physical environment affects well-being reflects common sense, evidence-based design is poised to emulate evidence-based medicine as a central tenet for healthcare in the 21st century."

Colin Martin

The Lancet August 2000

Healthcare Building Boom

• Aging facilities • Aging population • Bed shortages & capacity bottlenecks

Construction Cost Estimates:

$35 billion by 2009

Source: FMI

Evidence-Based Design Research

Evidence-based design is the deliberate attempt to base building decisions on the best available evidence.

EBD Research

Literature Search - 2004 • Robert Wood Johnson Foundation • Texas A&M, Georgia Tech • Ulrich and Zimring meta-analysis • 600+ studies • Published report, abstracts © 2007 The Center for Health Design ®

EBD Research

Literature Search - 2004 Rigorous studies link the environment to outcomes in four areas: 1.

Reduce patient stress 2.

Reduce staff stress 3.

Improve safety 4.

EBD Research

Patient Stress Scorecard

Reduce stress, improve quality of life and healing for patients and families

Reduce noise stress Reduce spatial disorientation Improve sleep Increase social support Reduce depression Improve circadian rhythms Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients & families Provide positive distraction Patient stress (emotional duress, anxiety, depression)

Ulrich & Zimring, 2004

EBD Research

Staff Stress Scorecard

Reduce staff stress/fatigue, increase effectiveness in delivering care

Reduce noise stress Improve medication processing and delivery times Improve workplace, job satisfaction Reduce turnover Reduce fatigue Work effectiveness; patient care time per shift Improve satisfaction

Ulrich & Zimring, 2004

EBD Research

Patient Safety Scorecard

Improve patient safety and quality of care

Reduce nosocomial infection

(airborne) (contact)

Reduce medication errors Reduce patient falls Improve quality of communication

(patient- staff) (staff

staff) (staff

patient) (patient

family)

Increase hand washing compliance by staff Improve confidentiality of patient information

Ulrich & Zimring, 2004

EBD Research

Quality Scorecard

Improve overall healthcare quality and reduce cost

Reduce length of patient stay Reduce drugs (see patient safety) Patient room transfers: number and costs Re-hospitalization or readmission rates Staff work effectiveness; patient care time per shift Patient satisfaction with quality of care Patient satisfaction with staff quality

Ulrich & Zimring, 2004

Research Conclusions

Many designs make hospitals more stressful and riskier for patients and staff.

A LOT of good evidence is available.

The evidence supports that good design can reduce stress and harm.

Research Conclusions

Immediate action • Provide larger single-bed rooms • Provide variable acuity rooms/reduce transfers • Reduce noise to reduce stress & improve sleep • Provide stress reducing views of nature • Develop efficient way finding systems • Improve ventilation and lighting • Provide positive distractions through the arts • Design to reduce staff walking & fatigue • Provide equipment to reduce staff injuries • Install visible/accessible hand washing facilities © 2007 The Center for Health Design ®

What is The Center?

The Pebble Project

Purpose

The Pebble Pioneers --IMPACT

Pebble Project Benefits

Bronson Methodist

Kalamazoo, MI • $181 million • December 2000 • $42 million less for new construction

Architecture & Interior Design: Shepley Bulfinch Richardson & Abbott

Bronson Methodist

Selected Data: Consumer Preferences 30 20 10 0 60 50 40 30 28 35 24 36 26 37 24 41 22 48 26 54 22 Dec'98 Dec'99 Dec'00 Bronson Dec'01 Nov'02 Competitor Nov'03 Nov '04 © 2007 The Center for Health Design ®

Bronson Methodist

20% 15% 10%

Bronson Methodist

Selected Data: RN Turnover 5% 0% 1998 1999 BMH 2000 2001 National Benchmark 2002 2003 2004 Q2 2005 Best Practices National Benchmark

Source for National Benchmark: The Advisory Board Source for Best Practices: ANCC

Bronson Methodist

The Bronson Lesson

A better building enhanced the well being of its patients, families and staff.

It also facilitated the cultural transformation that they were trying to achieve.

The Fable Hospital

How much does a better building cost?

To answer that, we invented The Fable Hospital.

Based on our Pebble Project ® partners’ measured experience using Evidence Based Design (EBD).

The Fable Hospital

• 300-bed regional medical center • Urban site • $240M replacement facility • Values: quality, safety, patients, families, staff, cost, value, community responsibility © 2007 The Center for Health Design ®

Unusual Culture

• Obsessed with quality and safety • Driven by values • Patient focused • Family friendly • A good corporate citizen • Determined to be eco-sensitive • Willing to benchmark • Want to be held accountable © 2007 The Center for Health Design ®

EBD Design Features

• Oversized, windowed, single rooms • Variable acuity rooms • Decentralized, barrier-free nursing stations • Additional hand-washing facilities • HEPA filters • Ceiling lifts © 2007 The Center for Health Design ®

Methodist Hospital

Indianapolis, IN Architecture & Interior Design: BSA LifeStructures

Edward Heart Hospital

Naperville, IL Architecture & Interior Design: Matthei Colin Associates

EBD Design Features, (

Bronson Methodist Hospital

The Fable Hospital

Detailed Construction Cost Estimates Example + $12 Million (5% of project cost)

The Fable Hospital

Savings & Revenue Example - Transfers

• Average cost of one transfer is $250-$300; • Fable’s acuity adaptable rooms helped reduce transfers by 80%. • Actual Pebble Project data from Methodist found a 90% decrease.

19,466 patient stays x $250 = $4,866,500 $4,866,500 x 80% = $3,893,200 savings

The Fable Hospital

Savings & Revenue Example - Patient Falls

• Unlitigated average cost is $10,000.

• National median is 3.5 falls/1,000 patient days.

• Fable’s unit & room design helped reduced falls by 80%.

• Similar to Pebble Project data from Methodist Hospital.

300 beds at 80% occupancy = 240 beds = 87,600 patient days/1,000 x 3.5

= 306 falls/year x $10,000 = $3,066,000 Reduced by 80% = $2,452,800 savings

The Fable Hospital

Savings - Infections

• 5-10% of patients get infections; average cost is $4,000 • Fable’s single bed rooms, HEPA filters, & location of hand-washing facilities helped reduce infections by 4 patients a month.

• Reimbursed 58% of additional costs from infections.

• Actual Pebble Project data from Bronson found 4-6 patients a month reduction.

4/month at $4,000 unlitigated cost = $192,000/year x 42% = $80,640 savings

The Fable Hospital

Savings & Revenue

(One-Year Savings) Fewer Patient Falls Fewer Patient Transfers

$2,452,800 $3,893,200

(- 80%) (- 80%)

Fewer Nosocomial Infections Reduced Nurse Turnover

$80,640

(- 4/m)

$164,000

(- 14%-10%)

Reduced Drug Cost

$1,216,666

(- 5%)

Total Cost Savings: $7,807,306

The Fable Hospital

Savings & Revenue

(One-Year Savings)

Market Share Increase Increased Philanthropy $2,168,100 $1,500,000 Total Revenue Gain: $3,668,100 + Total One-Year Savings: $7,807,306 Total : $11,475,406

The Fable Hospital

Cost avoidance savings alone, if we invested $7.8M at 3% for 30 years, it would pay the capital costs of the hospital many times over.

Life-cycle vs. one-time capital costs.

Once-In-A-Lifetime Opportunity

You are going to make an investment in new construction that can leave a lasting legacy to your organization and your community.

It can also improve quality/safety, lower operating costs and improve workforce morale. But to do so, ask question # 6!

Five Traditional Questions Boards & CEOs ask

Urgency 2.

Appropriateness 3.

Cost 4.

Financial impact 5.

1. Urgency

• Is the expansion/replacement actually needed now to fulfill the mission or can it be deferred? • For example, are the market and volume assumptions sound, and have other external factors that would affect the decision been honestly and accurately considered? © 2007 The Center for Health Design ®

2. Appropriateness

• Is the proposed plan the most appropriate and sound? • For example, have all alternatives been explored, such as partnerships with other hospitals and satellite operations as opposed to expanding or upgrading the facility in question?

3. Cost

• Has the project been reviewed to offer the maximum value for every dollar spent? • Is the cost appropriate for the expected level of construction quality in light of other projects being built in the region? (The “Ford vs. Cadillac” question) © 2007 The Center for Health Design ®

4. Financial Impact

• Has the operating impact of the additional volume been accurately analyzed financially?

• Has the operating impact of NOT proceeding also been analyzed?

5. Sources of Funds

• Have the sources of funds for the new facility been identified? • For example, is the combination of reserves, borrowing, philanthropy, and additional operating income reasonable and defensible? © 2007 The Center for Health Design ®

The Sixth Question Boards & CEOs MUST ask

Has management incorporated all the relevant evidence based design (EBD), which has been shown to positively impact quality, safety, satisfaction, productivity, and operational costs?

Incorporating EBD into the project can be a superb long term investment.

A Continuum of Design Changes We Can Make

•

Long Term

– Construction • Larger/variable acuity single rooms • HEPA filtration systems • Calming views and natural light • Wider bathroom doors • • • •

Short Term

Hand washing dispensers throughout Reduce noise – acoustics, pagers, loud equipment Create positive distractions through art and music • Install lifts • Improve way finding © 2007 The Center for Health Design ®

More Details

www.healthdesign.org

APPENDIX

“The hospital is a human invention and as such, can be reinvented any time.”

--Leland R. Kaiser, Ph.D.

Contact Information

Blair L. Sadler Former President & CEO Rady Children’s Hospital, San Diego Senior Fellow, IHI [email protected]

The Center for Health Design 1850 Gateway Boulevard Suite 1083 Concord, CA 94520 925.521.9404

[email protected]

www.healthdesign.org

What is The Center?

Mission

To transform healthcare settings into healing environments that improve outcomes through the creative use of evidence-based design.

Vision

A future where healing environments are recognized as a vital part of therapeutic treatment; and where the design of healthcare settings contributes to health and does not add to the burden of stress.

Multi-Disciplinary

• Healthcare management • Quality improvement • Patient satisfaction • Medicine & nursing • Architecture & interior design • Research & education • Strategic planning • Capital finance © 2007 The Center for Health Design ®

What The Center Does

Optimal Environments

Value Proposition • Strategic & business advantages • Safety & quality of care • Operational efficiency & productivity • Attract more patients • Recruit & retain staff • Increase community & philanthropic support © 2007 The Center for Health Design ®

DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE The Quality Colloquium Harvard University August 21, 2007 Blair L.

Transcript DESIGNING HOSPITALS FOR SAFE AND ECONOMICAL PRACTICE The Quality Colloquium Harvard University August 21, 2007 Blair L.

Today’s Learning Objectives

Institute of Medicine

Facts

Risks

Healthcare Workers

Components of Quality

Components of Quality

Making a Key Connection

“In service industries, the environment is the most objective and visible sign of respect for the patient, family and

.”

Healthcare Building Boom

Evidence-Based Design Research

Evidence-based design is the deliberate attempt to base building decisions on the best available evidence.

EBD Research

EBD Research

EBD Research

EBD Research

EBD Research

EBD Research

EBD Research

Research Conclusions

Research Conclusions

What is The Center?

The Pebble Project

Purpose

The Pebble Pioneers --IMPACT

Pebble Project Benefits

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

Bronson Methodist

The Bronson Lesson

The Fable Hospital

The Fable Hospital

Unusual Culture

EBD Design Features

Methodist Hospital

Methodist Hospital

Edward Heart Hospital

EBD Design Features, (

Bronson Methodist Hospital

Bronson Methodist Hospital

The Fable Hospital

The Fable Hospital

The Fable Hospital

The Fable Hospital

The Fable Hospital

The Fable Hospital

The Fable Hospital

Once-In-A-Lifetime Opportunity

Five Traditional Questions Boards & CEOs ask

1. Urgency

2. Appropriateness

3. Cost

4. Financial Impact

5. Sources of Funds

The Sixth Question Boards & CEOs MUST ask

A Continuum of Design Changes We Can Make

More Details

APPENDIX

Contact Information

What is The Center?

Mission

Vision

Multi-Disciplinary

What The Center Does

What The Center Does

Optimal Environments

Directory