A Policy of Evidenced-Based Design

Annual hospital construction costs in the United States are projected to rise from $19 billion in 2002 to over $27 billion in 2010. With the prospect of increasing fiscal constraints for hospitals, senior management will increasingly be required to justify the costs and benefits of proposed projects. As part of the enhanced awareness of their fiduciary responsibility following the recent corporate accounting scandals, governance boards of hospitals and their systems will likely require objective measures of the value of their investments. Recently, the British medical journal, The Lancet, carried a prediction by Colin Martin that "Evidenced-based design is poised to emulate evidence-based medicine, as a central tenet for healthcare in the 21st century." These trends will, in our view, increase the interest and utilization of evidence-based design and facilitate development of designs that improve medical outcomes, safety, patient and staff satisfaction, and operating performance.As a member of The Center for Health Design's Pebble Project, we hypothesized that patient-centric and medical staff directed facility design driven by data and innovation—and obsessed with safety—would improve medical outcomes and operating performance. We then established research designs to compare objectively measurable parameters before and after inpatient unit redesign.Two oncology units (comprising 25 and 29 beds) at the Karmanos Cancer Institute, located within The Detroit Medical Center, were selected for study. Basically, the design process aimed to create a healing environment that unified both staff and patient needs. Visioning, design and an iterative review process with patients and staff were used throughout the project. Elements of "clever class" were also incorporated into the plan, such as strategically placed wall sconce lighting and oval beveled-edge mirrors.In an attempt to quantify the design concepts, we chose to statistically evaluate if the following items were influenced by a renovated environment designed on the above principles and methods: reduction in pain medication requirements, improved patient satisfaction, reduction in nursing turnover, and lower variable operating cost per case.Our first assessment was 11 matched pairs (22 hospital stays) of sickle cell anemia patients who had a primary admitting diagnosis of vaso-occlusive pain crisis, with no secondary admitting diagnosis. During the winter months, these 11 patients were admitted to the old nursing unit, and then were readmitted to the renovated nursing unit, on another subsequent hospital stay, during that same season.These 11 patients were treated by the same medical team using the same written medical treatment protocol for both admissions. The patients were placed on Patient Controlled Analgesia (PCA) therapy, along with scheduled oral narcotics for pain control. The data demonstrated the comparable effectiveness of the treatment on the two units. The average pain score on admission were identical for both hospitalizations at 8.4, on a scale from one to 10; the average pain score on discharge was also identical on both old and renovated units at 5.5.The analysis showed that the patients on the renovated unit used 45 percent less PCA therapy to control their pain. This was statistically significant at p=0.03. The total narcotic used, excluding PCA therapy, was reduced by 16 percent on the renovated unit. Additionally, for this set of patients, the daily variable cost was reduced by 11 percent—a reduction of $43 per day. We theorize that the reduced use of narcotics to control pain to an acceptable level, as well as more efficient unit design contributed to the variable cost reduction.Our next assessment involved 417 men who received a radical prostatectomy. This surgical procedure was also protocol-based and involved the same surgical team in both units. We assessed 202 patients 12 months prior to the move (on the old unit), and 215 patients 12 months after the move to the renovated unit. The variable cost per case was 23.5 percent less on the renovated unit (p<0.01). The length of stay and complication rate remained the same for both groups. We theorize that these patients utilized fewer supplies and had a lower pain medication requirement, in addition to improved facility ergonomics.To provide a comparison of patient satisfaction outcomes, both pre- and post-renovation, a standardized evaluation instrument, Press Ganey Satisfaction Measurement Tool was used. The satisfaction scores rose dramatically, by 17 percent, post-renovation. This gain has been maintained, on the renovated units, since moving in. The frequency of medication variances in these units has trended downward but is not statistically significant given the limited observation periods and the small number of medication variances.Yearly nurse attrition rate within the renovated units is far less than the national average. Twelve months prior to moving to the renovated unit, the nurse attrition rate was 23 percent. A year after the move, the attrition rate fell to 3.8 percent. Staff vacancy rates are practically non-existent. These data contribute to the increasing body of research that evidence-based design improves medical outcomes and operating performance. The work of The Center for Health Design through the Pebble Project can help facilitate the development of such outcome measurements. As a policy, hospital management and governance should prospectively assess facility design projects on objectively measurable parameters to assure that the designs employed produce the desired medical, operational and financial performance. This policy will not only improve the design of individual projects, but will contribute to the general improvement of all health facilities by focusing on the results.Dr. Peters, a member of The Center for Health Design's Board of Directors, is the Karmanos Distinguished Chair of Oncology at the Karmanos Cancer Institute and President of the Institute for Strategic Analysis and Innovation the Detroit Medical Center. Dore Shepard was the principal investigator on the Pebble project described and has been a leader in nursing administration at the Detroit Medical Center and Karmanos for over 20 years. Both Peters and Shepard are principals in Insytex, LLC, a consulting firm involved in advising hospitals and boards on evidence-based design.