Health Design: The Fable Hospital

Editor's Note: This article is excerpted from "The Business Case for Better Buildings," which first appeared in Frontiers of Health Services Management, Vol. 21, No. 1, Fall 2004, p. 3-24. Used with permission from Frontiers of Health Services Management (Health Administration Press, Chicago).

Evidence-based design clearly is better for patients. We believe it also is better for every other healthcare stakeholder, including caregivers, investors and payers. Better healthcare buildings are a good investment.

To illustrate our case, we have created Fable Hospital, which is a composite of recently built or redesigned healthcare facilities that have implemented facets of evidence-based design in their facilities. Although Fable Hospital doesn't yet exist, we believe it will be built. Fable Hospital is a new 300-bed regional medical center built to replace a 50-year old facility that had 250 beds. Fable's per bed cost figure was $800,000. Located on a limited urban site, the hospital provides a comprehensive range of inpatient and ambulatory services, including medical/surgical, obstetrics, pediatrics, oncology, cardiac and emergency. Project cost of the total replacement project was $240 million.

Fable Hospital's core values include superior quality, safety, patient-focused care, family friendliness, staff support, cost sensitivity, eco-sustainability and community responsibility. Management engaged a philosophically aligned design team based on the premise that the building should reflect the organization's core values and strategic aspirations. The designers responded with an array of design innovations and upgrades for the new facility, including the following:

• OVERSIZED SINGLE ROOMS with dedicated space for patient, family and staff activities and sufficient capacity for in-room procedures. The design maximizes daylight exposure to patient rooms and work spaces.
• VARIABLE ACUITY ROOMS standardized in shape, size and headwall to eliminate the need to move patients as their condition changes.
• DOUBLE-DOOR BATHROOM ACCESS enabling caregivers to more easily assist patients to and from the bathroom on foot, in wheelchairs, or in their beds.
• DECENTRALIZED, BARRIERFREE NURSING STATIONS that place nurses in close proximity to their patients and supplies, most of which are stored in or near patient rooms.
• ADDITIONAL HAND-WASHING FACILITIES located conveniently to encourage staff to use them to reduce transmission of infections and enabling patients to see them being used.
• HEPA FILTERS to improve the filtration of incoming outside air and eliminate re-circulated air.
• FLEXIBLE SPACES for advanced technologies including operating rooms sized for robotic surgery, endovascular suites for minimally invasive surgery with sophisticated imaging, and imaging rooms designed to support continuous equipment advances.
• PEACEFUL SETTINGS including artwork displays, space to listen to piano music, and gardens with fountains and benches to moderate the stress of building occupants.
• NOISE-REDUCING MEASURES including sound-absorbing ceilings and a wireless communications system that eliminates overhead paging, to moderate the stress of building occupants.
• CONSULTATION SPACES conveniently located to facilitate private communication between caregivers and families.
• PATIENT EDUCATION CENTERS on each floor offering brochures, books, videotapes and Internet access to diseasespecific information and online support groups that improve patient and family understanding of illness.
• STAFF SUPPORT FACILITIES including a staff-only cafeteria, windowed break rooms with outside access, a day-care facility, and an exercise club.

These design innovations and upgrades collectively added $12 million to the construction budget. In addition to these facility design investments, Fable also invested in computerized order-entry and bar code verification technology to minimize medication errors and improve operational efficiency.

Fable's CEO shared with the board an initial financial and performance impact assessment of the incremental facilities investment one year after occupying the new building. The assessment was based on management monitoring a series of key performance indicators in the 12 months since opening, part of a planned five-year evaluation program.

Seeking to be conservative in the analysis, the CEO adjusted downward certain estimates of increased savings and revenues to reflect positive influences other than the new building. The CEO wished to eliminate any concerns that the new facility was given more credit for improvements than warranted. The expense numbers also were adjusted to reflect the larger number of patients served in the new facility.

Even with the adjustments, the CEO was surprised by the significant first-year savings and revenue gains attributed to the facility. Reduced patient falls, transfers, nosocomial infections, drug costs, nursing turnover, as well as increased market share and philanthropy added up to savings and revenue gains of $11.4 million. In all cases, the numbers are based on actual performance results of organizations that are participating in The Center for Health Design's Pebble Project research initiative. Like Fable's CEO, we sought to be conservative in calculating our estimates and believe Fable's first-year gains actually could be much greater.

Is Fable Hospital a pipedream? Can a more expensive building that is better for patients and their caregivers actually provide the financial gains indicated in the Fable case study? We believe the answer can be "yes" with values-driven hospital leadership, supportive hospital boards, talented designers, and a willingness to embrace the lessons of evidence-based design.

The Moral of The Story
Illness costs—both human suffering and financial expenditures exact high prices. Conversely, well-being pays dividends—both persons and profits are healthier. Investment in better healthcare buildings pays off directly and indirectly through enhanced patient care and employee well-being.

In a world that has begun to understand its resources as finite, maximizing the benefits realized for every dollar invested becomes crucial. The business case for better hospital buildings is strong. In this composite case study of Fable Hospital, based on the actual performance of Pebble facilities, our estimated savings and revenue gains nearly recapture the incremental investment in a better building in just the first year. The concept of evidence-based design offers an attractive alternative to the status quo and invites further exploration.

Fable Hospital does not exist, at least not on one site or in one facility. Fable serves as an idealized template to demonstrate how evidence-based design can improve patient and staff satisfaction, medical outcomes, safety, cost efficiency, resource conservation and financial performance. Given the forecasted construction boom for the U.S. healthcare industry in the decade ahead, evidencebased design offers better health outcomes for patients and more cost-effective solutions to providers, employers, health plans and government agencies.