CEO Michael Covert speaks so rapidly and excitedly about the marvels of his $1 billion Palomar Medical Center north of San Diego, which accepted its first patients on Sunday, he just might forget to breathe.
For quality design, the glass and steel structure "will be the most advanced—based on the size of the project and what's happening in the rest of the country—for at least the next several years," he boasts. With 288 single-bed rooms, Palomar embodies the healthcare conceptualist's apocryphal "Fable Hospital," he says, and is the quintessence of "the Hospital of the Future."
"The things we're doing with technology will remain unique compared to what others are doing. And though they may have newer or bigger facilities with more money, a lot of the features we're talking about they're not going to have because they aren't designed with that in mind," Covert says.
Blair Sadler, who authored several papers documenting the business case for quality improvement through architecture and who oversaw two drastic design changes during his 26 years as a large children's hospital CEO, thinks Covert got a lot of it right. That's unlike other CEOs who postpone such changes or are making the wrong ones, Sadler says.
"My experience is still that the majority of CEOS don't get the powerful connection between the physical space of a hospital and its quality," says Sadler, now a senior fellow with the Institute for Healthcare Improvement.
Though extremely competent and dedicated, they tend to delegate the remodeling process to their facilities people, who respond to what doctors, nurses and board members want, not to what the latest evidence for improving quality of care suggests or what the patients need, he says.
"Atriums win architecture awards, but they don't save lives," Sadler says.
More efficient use of nursing time, less time spent looking for needed equipment, safer bathroom configurations, natural light, and reductions in noise can all have a payoff that can lower errors and the need for care that won't get reimbursed.
Sadler says studies show how reducing the number of times a patient is handed off or must be wheeled around the hospital reduces errors and infections, and allowing families more time with patients can reduce length of stay.
Quality improvement through design
Which brings us back to Palomar. Its new 740,000 square-foot, 11-story building is part of a three-hospital system that makes up the largest hospital district in California. It serves Escondido, a 146,000-population suburb about 30 miles north of San Diego, replacing a 300-bed facility that is 62 years old. Palomar has a 500,000 patient catchment of 800 square miles.
Yes, the $522.7 million University Medical Center of Princeton, NJ, which opened May 22 with 231 beds, incorporates many of the same technologies. So does the Department of Defense's $1 billion, 120-bed Fort Belvoir Community Hospital in Virginia, which opened last September, or the $1.1 billion, 560-bed Johns Hopkins Hospital in Baltimore, which opened May 1.
But Palomar gets more points, Covert says, because among the 20 features that set it apart, the facility is incorporating seven or eight evidence-based features that no one else has.
Flowing water cues hand-washing
1. 120 of the hospital's rooms are technologically capable of being instantly converted to an intensive care unit, "allowing you to escalate or de-escalate as needed." This avoids moving patients around the hospital, reducing the risk of handoff errors or infections.
2. Faucets in each patient room start running water when their infrared devices signal a newcomer has arrived, a reminder to wash their hands. "We know that has the potential to reduce infections," Covert says.
3. There are no nursing stations. Instead, nurses' activities take place at a small workstation just outside each room in a way that allows them to chart while observing and talking with the patients. This is intended to reduce errors.
4. Adjacent to those stations are supply closets so staff don't waste time being "hunter-gatherers" running around to locate what they need.
5. 120 rooms have 550-pound hydraulic lifts device built into the ceiling to assist healthcare workers who need to move heavy patients. That saves time and reduces occupational injuries.
6. 120 rooms have the capability to perform renal dialysis so patients don't need to be moved.
7. Every 320-square foot room is wirelessly connected to an electronic medical record system so providers can document care in the patient's chart through a handheld device or laptop.
8. Operating rooms, cardiac cath labs, and interventional radiology suites are intertwined, and each can be quickly adapted for another use without moving the patient. "If we need more cath labs, we can change that overnight," Covert says. "I don't know of anyone else in the country who has that."
9. Part of the hospital has been designed under a "superdome" to enable MRI or CT machines to be replaced with newer models without having to tear out walls.
Infection zappers, wireless vital sign monitoring
10. All wiring and piping runs through an "interstitial space" between floors so that if anything goes wrong, repairs can be done without breaking a sterile field or opening walls. "Nobody else has that that I know of today," Covert says.
11. Palomar has designed a special suite for future robotic surgery in such a way that the only living thing inside it is the patient. "Everything else in it is a robot, the nurse, circulating nurse and the robotic arms and devices used by physicians in the next room, or a mile away."
12. Palomar is leasing four Xenex PX-UV machines that move into rooms in between patients. Within six minutes, certain bacterial microorganisms are destroyed.
13. Sotera Wireless VISI's vital sign monitoring system just cleared U.S. Food and Drug Administration's 510(k) process, and Palomar is the first hospital to use it for ambulatory patients. Covert describes it as "equivalent to putting on EKG leads that are tied to a smartphone-like device," which can be read on an iPad. Now patients can move or be moved wherever they need to be without losing monitored vital sign connectivity.
14. Gone are physicians and nurses lounges. Instead, each floor has a multipurpose room that "actually forces our doctors and nurses to come together to talk with each other about their patients and complete their work together."
15. Adjacent to each bed is a line of handrails to give patients support if they try to move to the toilet or shower, eliminating an expensive risk for falls.
Concealing operations from public view
16. Of the 17 elevator bays, several are dedicated exclusively for sterile use or staff use so operations the patient shouldn't be exposed to—patient transport, laundry, food service and supply deliveries—take place out of public view.
17. Families have a place in the ICU to sleep next to the patients, night and day, with room service.
18. A time-saving circuit connects 80 pneumatic tube stations allows medication and paperwork to zip through the hospital.
19. Patients can control lighting, TVs, room service, windows, temperature and other ambient aspects of their rooms from their beds. All patient rooms are configured identically, enabling providers to always know where things are.
20. Outdoor garden areas on every floor give patients and their families the ability to walk outside without having to go downstairs and leave the building.
Covert emphasizes the project's biggest achievement is one he likes to call "the f word," by which he means flexibility. "The thing that was my greatest concern when we started down this process was that when we were finished, the world would have changed," he says. He feared Palomar would be like so many other facilities, obsolete.
Palomar has set itself up as the most recent proving ground for whether these design changes and dollars spent do improve quality outcomes. So the quality of so many hospitals of the future, still a glimmer in their designers' eyes, depends on a careful look at Palomar to make sure they did get this right.