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Evidence-Based Hospital Design Improves Patient Safety

Tami Swartz, April 28, 2009

Dublin (OH) Methodist Hospital has not had a hospital-acquired infection since January 8, 2008, when it opened. Chief Nursing Officer Lamont Yoder, RN, attributes the hospital's infection control success not just to its staff members' compliance, but to the physical environment in which they work every day.

"Private rooms are not just for the luxury of having a private room," says Yoder. "They're actually for the [patient's] outcome afterward."

Private rooms are not the only design helping Yoder keep his hospital a safe place to heal. Dublin Methodist was designed with consultation from the Center for Health Design (CHD), a non-profit research, education, and advocacy organization that conducts research to guide hospitals on best design practices for healthcare organizations.

Hundreds of research reports conducted by the center have gathered evidence on the impact of healthcare design on patient care, quality, outcome, and safety.

"The work [the CHD has] done over these last 10 to 20 years have shown quite conclusively that physical environment actually makes a difference to patient safety and quality improvement," says Anjali Joseph, PhD, director of research at CHD. "What we've been suggesting is that physical environment should be a part of the bundle of interventions that are put in place."

Dublin Methodist is contributing to more research as a partner in the Center's Pebble Project, which aims to collect information on newly-designed hospitals to find out what works best. "Patient safety was our top strategy in how we designed the building, from an architectural and work flow standpoint," says Yoder.

In November, 2008, the Joint Commission released its Guiding Principles for the Development of the Hospital of the Future, a report that guides hospitals in meeting the challenges of the future. Hospital design was one of its five core areas of action. In the report, the Joint Commission urges hospitals to offer private rooms, decentralize work stations, and reduce noise through evidence-based design.

More recently, the Institute for Healthcare Improvement published Using Evidence-Based Environmental Design to Enhance Safety and Quality, as part of its Innovation Series 2009. Joseph served as one of the paper's authors. The paper attempts to highlight the connection between world of hospital and patient safety and that of architectural design.

Private rooms, fewer transfers
Apart from patients having their own rooms at Dublin Methodist, they also move around much less, which Yoder says reduces infection rates.

"This is probably one of the most unique aspects in the design," says Yoder, referring to the hospital's acuity adaptable model of care, which allows any patient to stay in the same room until he or she is discharged, "no matter what happens to them in the hospital" according to Yoder.

"We don't have geographically delineated locations for certain types of patients. We don't have a medical floor, then a surgical floor, and then an intensive-care unit (ICU)." Instead, rooms are adaptable and medical equipment and nurses are brought to the patient.

Better light, less noise
Light and noise are both significant areas of interest for the CHD. Natural light in patient rooms can help patients gain better orientation, decreasing confusion in some patients, and is associated with both a shorter length of stay and lower use of pain medications, says Yoder. And though Joseph says there hasn't been much research to determine the environmental effects on medical errors, one CHD study found better lighting in the pharmacy lowers medication dispensing errors.

"We have an extremely, extremely quiet environment," says Yoder, explaining that this improves patient sleep patterns and communication between staff members and physicians, as well as between patients and their caregivers. Yoder says most hospitals are at the decibel level of highway traffic. Although most healthcare workers would probably not be surprised by that estimation, says Yoder, the noise can affect care.

"Those of use who have worked in busy units know that it can become extremely loud during shift change, when you have multiple nurses, caregivers, and physicians in an area where they all gather together. Our ability to lower noise was done by having no centralized location for people to gather," says Yoder.

Dublin Methodist has no centralized nursing stations; instead, it has working areas called perches, which are smaller, sitting or standing height stations closer to patient rooms. From each perch, a nurse can see three to five rooms. The perches also eliminate communication barriers.

Environment of safety in older hospitals
Though Yoder concedes that having breakthrough design and technology helps reduce errors and improve patient safety, he says that without the implementation of a culture of safety—which he adds can be implemented at any hospital—it wouldn't be enough.

"You can have the most beautiful building that is designed with the greatest architectural pieces that add into outcomes, but if you don't have the culture of safety developed, it will not work."

In addition to implementing a culture of safety, Joseph says any hospital should consider small implementations to improve the safety of its environment. She suggests conducting light and noise audits, ensuring there is enough light in critical spaces such as pharmacy, and find the source of loud noises to see whether the source can be removed. Installing sound-absorbing ceiling tiles, if possible, helps reduce noise, while rubber floors reduce noise and soften patient falls. She also suggests adding visual cues to highlight hand washing facilities.


Tami Swartz is an associate editor at HCPro, Inc., where she serves as editor for books, videos, and other resources in the accreditation and quality/patient safety markets. Tami also writes for Briefings on Patient Safety, an HCPro monthly publication. Contact Tami by e-mailing tswartz@hcpro.com

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