Designing for Safety and Quality
Transforming Hospitals: Designing for Safety and Quality, a DVD from the Agency for Healthcare Research and Quality (AHRQ), reviews the case for evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of care, and employee retention, and results in a positive return on investment.
This summary discusses evidence-based design, patient safety and satisfaction, quality outcomes, staff satisfaction and retention, and cost effectiveness.
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Select for print version (PDF File, 419 KB). PDF Help.
Web Conference
AHRQ hosted a free Web conference on evidence-based hospital design July 16, 2008. Leaders in medicine and health care design shared personal stories about how evidence-based hospital design helped them create safer and more effective facilities that enhance patient safety, improve the quality of care, increase workforce satisfaction, and reduce the cost of care. The archived Web conference is available; go to the bottom of the page and select the "Lauch Presentation" button. A full transcript is also available.
Note: If you cannot view the event, your computer system may not have the necessary software applications. To determine if this is the issue, select the "Test Your System." You can also select one of the following links: Real Player® or Windows® Media Player to verify that your computer is configured to stream media. For other technical issues, please contact Dana Stelmokas at Hospital_Technical_Assistance@AHRQ.hhs.gov or phone 1-800-833-2812.
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Contents
Background
Evidence-Based Design
Patient Safety
Patient Satisfaction
Quality Outcomes
Staff Satisfaction and Workforce Retention
Cost Effectiveness
Order the DVD
For More Information
Resources
References
Background
The 1999 Institute of Medicine's landmark report, To Err is Human: Building a Safer Health System, exposed the tremendous costs, both in human and financial terms, of medical errors in the U.S. health care system.1
Two studies cited in the report indicate that between 44,000 and 98,000 people die each year in the United States as a result of medical errors. The national cost to the economy of these errors is between $17 billion and $29 billion. Since the release of the Institute of Medicine's report, a number of successful initiatives have been launched to help hospitals change their cultures and care processes to produce safer health care environments with fewer medical errors.
A growing body of literature describes the link between a hospital's physical design and its key quality and safety outcomes. Hospital planners, expected to spend nearly $250 billion on new construction in the next 10 years, are consulting this evidence and incorporating it into their designs for capital construction projects.2
In the midst of this construction boom, hospital planners have an opportunity to create safer and more effective facilities that enhance patient safety, improve the quality of care, increase workforce satisfaction, and reduce the cost of care.3 In an era of staff shortages, increased transparency of information about hospital performance, and reimbursement linked to performance, improving health care environments may be critical to a hospital's survival.
Transforming Hospitals: Designing for Safety and Quality, a DVD from the Agency for Healthcare Research and Quality (AHRQ), reviews the case for evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of care, and employee retention, and results in a positive return on investment.
The DVD presents the experiences of three model hospitals—Griffin Hospital in Derby, CT; Holy Cross Hospital in Silver Spring, MD; and Woodwinds Health Campus in Woodbury, MN—that incorporated evidence-based design elements into their construction and renovation projects.
Hospital executives planning or executing a major capital construction project or minor renovations can use the information presented in this DVD to help identify how evidence-based design can improve the quality and safety of their hospitals' services.
Select to order the DVD.
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Evidence-Based Design
Evidence-based design is a term used to describe how the physical design of health care environments affects patients and staff.4,5 Key characteristics of evidence-based design in hospital settings include single-patient rooms, use of noise-reducing construction materials, easily accessible workstations, and improved layout for patients and staff.6
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Patient Safety
Evidence-based design elements can help hospitals reduce costly and avoidable incidents of patient harm, such as:
- Patient falls.
- Hospital-acquired infections.
- Medication errors.
Patient Falls
Patient falls, which are common in hospitals, can result in serious injuries, extend a patient's stay, and drive up the cost of care significantly. By 2020 the estimated annual cost of fall injuries for older people will exceed $30 billion.7-8 Now that the Centers for Medicare and Medicaid Services no longer reimburse hospitals for the cost of patient falls that occur in their facilities, and insurers are likely to follow its lead, hospitals will bear a greater portion of this cost.
Patient falls can be avoided. Poor placement of handrails and small door openings are two primary causes of patient falls. Many falls can be reduced through providing well-designed patient rooms and bathrooms and creating decentralized nurses' stations that allow nurses easier access to at-risk patients.9-11
Hospital-acquired Infections
Single-bed rooms and improved air filtration systems can reduce the transmission of hospital-acquired infections. Infections can also be reduced by providing multiple locations for staff members to wash their hands so they spend less time walking to sinks and have more opportunities to sanitize their hands before providing care.12
Medication Errors
Poor lighting, frequent interruptions and distractions, and inadequate private space can complicate filling prescriptions. Well-illuminated, quiet, private spaces allow pharmacists to fill prescriptions without the distractions that may lead to medication errors.13
Patient rooms that can be adapted for the acuity of a patient can also reduce errors. Acuity-adaptable rooms reduce the need to transfer patients around the hospital and lessen the burden on the staff to communicate information to caregivers in the patient's new location.14
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Patient Satisfaction
Reducing noise, providing more privacy, and making it easier for patients to find their way though the hospital can all improve patient satisfaction.
Frequent overhead announcements, pagers, alarms, and noisy equipment in or near patient rooms are stressful for patients and interfere with their rest and recovery.15 Single-bed rooms with high-performance, sound-absorbing ceilings and limited overhead announcements can substantially improve the healing environment for patients.16
Evidence also shows that patients are more satisfied with their care when they are given adequate space to interact with their families. For example, single-patient rooms make it easier for families to stay with patients.17 Responding to the overwhelming evidence regarding how single-patient rooms improve patient safety, satisfaction, and quality outcomes, the American Institute of Architecture changed its 2006 construction guidelines to recommend that single rooms for medical, surgical, and postpartum nursing units in general hospitals be the standard.18-19
Helping patients effortlessly find their way through hospitals can improve patients' overall care experience and increase satisfaction by reducing feelings of stress, anxiety, and helplessness for them and their families. Better navigation can be addressed architecturally through useful signage and easily navigable corridors.20
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Quality Outcomes
Several design elements are associated with better quality outcomes for patients. In addition to improving patient satisfaction, reducing hospital noise can improve patient recovery and sleep time and reduce depression. Other factors, such as increased sunlight in patient rooms, views of nature, artwork, and music, also reduce patient stress and can lead to improved outcomes.21
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Staff Satisfaction and Workforce Retention
Staff shortages and turnover are serious problems for hospitals. The staff shortages and turnover are serious problems for hospitals. The average annual turnover rate for health care workers, many of whom are nurses, is 20 percent, and much of this turnover is related to stress, which could be greatly reduced by lessening the physical demands of nursing.22-23
One example of how to reduce the physical burden on staff and improve workflow is by using acuity-adaptable rooms, which limit the need to transfer patients within the hospital. By reducing the number of moves, hospitals can increase productivity in delivering patient care and decrease the physical demands on the staff.24-25
Another useful design element decentralizes nurses' stations and supply areas to allow nurses to spend less time walking and more time treating patients.26 Reducing stressful noise; improving light sources for surgical staff; and designing patient beds to reduce back stress, fatigue, and injuries can also improve workforce satisfaction and retention.27
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Cost Effectiveness
The competitive nature of health care, new medical technology that requires facility upgrades, and the need for health organizations to become more efficient and cost effective have driven the recent upward trend in hospital growth. To meet these challenges, hospitals require frequent updates to meet current guidelines and regulations and maintain market share.28
Although designing an updated facility using evidence-based design principles may add up-front capital costs, this investment ultimately decreases medical and financial complications that can result from a poorly designed facility.29-31 The Center for Health Design modeled and analyzed the increased capital costs and downstream cost-savings of well-designed facilities by using a "fable hospital" that included many common evidence-based design elements. While these features added $12 million to the cost of the hospital construction, those costs were projected to be recovered in one year through operational savings and increased revenue.32
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Order the DVD
To order a copy of Transforming Hospitals: Designing for Safety and Quality (AHRQ Publication No. 07-0076-DVD):
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For More Information
Contact the AHRQ Office of Public Affairs:
- Ellen Crown: (301) 427-1258.
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Resources
Improving the Health Care Environment and Processes
1. Mistake-Proofing the Design of Health Care Processes
(Web Version; PDF File, 1.6 MB, PDF Help)
Synthesizes more than 150 practical examples from real world health care on using process or design features to prevent medical errors.
2. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? (Web Version; PDF File, 700 KB, PDF Help)
Architects, designers, academics, and health care executives discuss the associations between hospital building design elements and patient and staff safety, health outcomes, and patient and staff satisfaction levels.
3. A Toolkit for Redesign of Health Care (Web Version; PDF File, 350 KB, PDF Help)
Strategies for comprehensively redesigning and transforming the processes for care in a hospital.
4. The Effect of Health Care Working Conditions on Patient Safety: Evidence Report/Technology Assessment, No. 74 (Web Version; PDF File, 740 KB, PDF Help)
Scientific information on which to base clinical guidelines, performance measures, and other quality improvement tools.
Evidence-Based Design
The American Institute of Architects: www.aia.org, especially Guidelines for Design and Construction of Health Care Facilities
The Center for Health Design: www.healthdesign.org, especially The Role of the Physical Environment in the Hospital of the 21st Century
InformeDesign: www.informedesign.umn.edu
Institute for Healthcare Improvement: www.ihi.org.
Planetree: www.planetree.org, especially Designing and Practicing Patient-Centered Care
Robert Wood Johnson Foundation: www.rwjf.org
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References
1. Institute of Medicine, Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS, Eds.) Washington, DC: National Academy Press; 2000.
2. The Center for Health Design. Scorecards for Evidence-Based Design. Concord, CA; 2005 Dec.
3. Evidence-Based Hospital Design Improves Healthcare Outcomes for
Patients, Families, and Staff. Princeton, NJ: Robert Wood Johnson Foundation; 2004 Jun 7.
4. Hamilton DK. Four Levels of Evidence-Based Practice. Healthcare Design; 2003 Nov; 3:18-26.
5. Blum, A. How Hospital Design Saves Lives. BusinessWeek Online; 2006 Aug 15.
6. The Center for Health Design. Scorecards for Evidence-Based Design. Concord, CA; 2005 Dec. Available at www.healthdesign.org/research/reports/documents/scorecard_12_05.pdf.
7. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
8. Chang J, Morton S, Rubenstein L, et al. Interventions for the Prevention of Falls in Older Adults: Systematic Review of Meta-Analysis of Randomized Clinical Trials. Br Med J; 2004 March 20; 328:680-6.
9. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
10. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
11. Brandis S. A Collaborative Occupational Therapy and Nursing Approach to Falls Prevention in Hospital Inpatients. J Qual Clin Pract; 1999; 19(4):215-220.
12. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
13. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
14. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
15. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
16. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
17. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
18. The American Institute of Architects. Guidelines for Design and Construction of Health Care Facilities. Available at www.aia.org/aah_gd_hospcons. Accessed March 22, 2005.
19. Chaudhury H, Mahmood A, Valente M. The Use of Single Patient Rooms Versus Multiple Occupancy Rooms in Acute Care Environments. Submitted to The Coalition for Health Environments Research; 2003 Nov 20.
20. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
21. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
22. Joint Commission of Accreditation of Healthcare Organizations. Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis; 2002.
23. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
24. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
25. Hendrich AL, Lee N. Intra-Unit Patient Transports: Time, Motion, and Cost Impact on Hospital Efficiency. Nurs Econ; 2005 July 1; 23(4):157-64.
26. Hendrich AL, Bender, PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Appl Nurs Res; 2003; 16(1):9-21.
27. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
28. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality; 2005 Aug. AHRQ Publication No. 06-0106-EF.
29. Blum, A. How Hospital Design Saves Lives. BusinessWeek Online; 2006 Aug 15.
30. The Center for Health Design. Better Hospital Buildings Cost More, but Pay for Themselves Through Increased Revenue and Operational Savings; 2004 Sept 8. Available at www.healthdesign.org/aboutus/press/releases/2004-09-08_frontiers.php. Accessed Mar 22, 2007.
31. Landro, L. Hospitals Build a Better "Healing Environment." Wall Street Journal Online; 2007 Mar 21.
32. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
AHRQ Publication No. 07-0076-1
Current as of September 2007
Internet Citation:
Transforming Hospitals: Designing for Safety and Quality. AHRQ Publication No. 07-0076-1, September 2007, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/transform.htm
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