 My worst nightmare has been that we would do something harmful to a child. What keeps me awake at night is how we explain to families that we caused their family member to die. Turnover rates cost money. Turnover rates cause quality problems. Government payment, insurance companies payment, bed shortages, staffing shortages. I worry about injuries to patients. I worry about mistakes. I worry about falls. Simply going to the hospital is a leading cause of death in the United States. It's estimated that hospitals in the U.S. will spend nearly $250 billion in new construction over the next 10 years. This gives us a unique window of opportunity for us to rethink our healing spaces. At the Agency for Healthcare Research and Quality, we've been asking, how can we build hospitals that accommodate improved models of care and new technologies, enhance working conditions for staff, and address patient safety issues like hospital-acquired infections, falls, and medical errors? We want to design hospitals so that they are more efficient, safer, and less stressful and exhausting for staff. We also want to make sure that they provide patient and family-centered care. Their continuing efforts to create safer and more effective facilities, many of America's top healthcare institutions are adopting a structured process of evidence-based design. They're basing their designs on an expanding body of scientific research, and they're documenting solid results, not only making their hospitals safer and less stressful, but also less expensive to run. The process requires a CEO willing to set ambitious safety and quality goals to involve experts who know the evidence and to do follow-up testing to see if they've met their goals. Really the core of evidence-based design is using research. Just like evidence-based medicine uses research to find out clinically how things work better, evidence-based design is about using rigorous research to see how the physical environment really does have an impact on health or economic outcomes. The evidence shows that a modest one-time incremental capital cost to reduce noise, patient falls, and infections, create single variable acuity rooms, improve efficiency, and reduce stress for staff and patients will produce significant operating savings year after year. Noise has often been considered a nuisance. However, it's a major health hazard. It leads to miscommunication, which can lead to errors, it increases stress and fatigue, and most importantly, it disrupts one of nature's best healers, sleep. The research shows that carpet, noise-dampening ceilings, and other relatively inexpensive measures actually contribute to healing. The cost of patient falls in suffering, loss of life, and dollars is enormous, but investing in inexpensive solutions like this shower with no lip to trip over can yield large returns. With a traditional door, it's just wide enough, the patient can go through, the family member can't, or the nurse can't, they let go of the patient, the patient slumps to the floor and falls. So even relatively simple measures like making four-foot wide rather than three-foot wide bathroom doors turns out to be actually quite significant issues. Every time somebody falls in a hospital and extends their stay, it costs a hospital $10,000 if that's not litigated. Single rooms don't just offer dignity and privacy. They improve safety and provide long-term savings. We now have solid research studies to show that patients who are in multi-bedded rooms are at far higher risk of error, complications, infection. Nearly 2 million patients acquire infections while in the hospital. 80,000 of them die from these infections each year, costing hospitals an average of $27,000 apiece. Many deaths could be prevented by better air filtration and more frequent hand washing. Simply by locating these hand washing facilities closer to movement paths within the field of view of nurses as they approach the patient's head, close at hand we can produce substantial long-term or sustained increases of hand washing, as much as 70 or 75% increases. Designing single variable acuity rooms, rooms where patients can stay in the same room but receive all levels of treatment, can reduce patient moves, which are dangerous both for patients and the people who move them. Firstly, we need to think of injury risk in lifting alone. Secondly, we need to think of the time it takes to transmit the information to the new care team, assuming that that care team might change completely. And then thirdly, we need to think about transmission of infection. Staff recruiting and retention are serious problems for CEOs. Simple design choices like lifts, whether built-in or portable, reduce injuries to patients and staff and save on labor. At Peace Health in Eugene, Oregon, lifts cut nurse back injuries by 80% and paid for themselves in two and a half years. Inefficient work areas increase stress and fatigue and keep nurses from their patients. They waste money and drive good nurses from the profession. Dr. Marilyn Chow and I did a study recently that looked at 36 medical surgical units and what we found was that nurses spend the least amount of their time in direct patient care activities and the majority is spent hunting and gathering equipment, walking to and from locations on a unit. So it's a very inefficient environment that we've created. Nationally there's about a 20% rate of turnover for nurses alone and the cost, according to Robert Wood Johnson, is almost $70,000 for replacement. Is evidence-based design cost effective? The Center for Health Design modeled a new hospital, which they called a Fable Hospital with 300 beds and costing $240 million. It estimated that an additional investment of $12 million in designs for improved safety and quality would pay back the investment in the first year. We are in the midst of a profound sea change in healthcare and it is a change towards transparency of information, particularly measurement and public reporting of all kinds of quality and cost indicators. And that will put enormous pressure in turn on institutions to perform. Even the ability of a hospital to borrow money will be affected in the future by measures of quality. CEOs report an additional benefit of evidence-based design. It gives a hospital the chance to rethink its culture and care models to ask not only how it can increase efficiency, but how we should define it. We'll see what's going on. Efficiency for the nurse, efficiency for the insurance company, efficiency for the hospital administrator. That was fun. Or should we really be talking about patient-centered efficiency and patient-centered evidence-based design? In any construction project, large or small, it's not the architects and designers but the CEO who understands the culture and the care model of the hospital who has to be the vision keeper. We wanted to create more public space, larger patient rooms, bigger windows, bathrooms in every room. And we wanted to do it at the cost of a traditional facility and we've proven that it can be done. One of the other really important guiding principles at Woodlands is to challenge the status quo. Boards of trustees and CEOs and leadership teams often get only one time in their whole career to build a new hospital where we replace much of the hospital. The chance and the opportunity, in fact, the obligation to do it right, to use the best knowledge we have, is enormous. We cannot afford to miss that opportunity. It's going to make a difference in patient's lives, caregiver's lives, and it's going to have a positive economic benefit. Try to think about perfectly designed hospital and it would be more reliable, fewer mistakes, fewer drop-offs. So everything would, there'd be precision, promises kept. It would be peaceful, healing, a quiet place where patients can use their limited energy to get better instead of to fight the environment. And most especially the loved ones of the patients are there all the time. There'd be a sense of things in their place and a place for everything. I think it would be simpler. I think the clutter and the complexity and the machines and the bells and the whistles need to be managed out of the care. I think it would feel more like home probably and therefore it has to be more customized. And somehow all of this resting on science because we're there in a technical enterprise that has to use knowledge and machines and drugs correctly so underneath all is confidence that we're going to do the right thing every single time. Whether building a new hospital or making modifications to an existing facility, evidence-based design offers hospital leaders an opportunity to shape the quality and cost of healthcare in their community for years to come. The Agency for Healthcare Research and Quality recommends that all hospitals, architects and designers learn more about the evidence-based design process and that they include professionals on their team who are experienced in incorporating the best available research into their work. Leaders can start now by watching the case study video included on this DVD and by familiarizing themselves with the wealth of research in this growing field.