 Welcome. I'm Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality. We have developed this DVD in two parts. In the first introductory session, we've gathered the views of leading researchers, CEOs, board members, doctors, staff and patients who've been instrumental in building new hospitals, combining good medical science with safer and more welcoming design. In the second section, we will give some examples of three hospitals that have used evidence-based design successfully. Along with the three hospital case studies that follow, you also will hear about other leading health facilities throughout the United States regarding their experiences with evidence-based hospital design. The case studies and other testimonials explain how the physical environment of a healthcare facility can improve the safety and quality of a hospital experience for patients and staff. Beyond discussing issues of safety and quality, the DVD also makes the business case for the long-term cost-effectiveness of using evidence-based hospital design principles when building or renovating hospitals. We took my mother-in-law after a very serious fall to the emergency room trauma center and my wife and I ended up sitting on the floor of an examination space that I designed. They were big and overwhelming and noisy. You're certainly not going to rest in a hospital. My mother entered the hospital again the last time and she died of, I believe, hospital-enquired infections of a wound that she got in the hospital. Just as evidence-based medicine uses research to find out clinically how things work better, hospitals are using evidence-based design to see how the physical environment can improve both medical and economic outcomes. There is a very close link between the built environment and the outcomes for patients and the outcomes for staff that it can make a very big difference as to whether patients get better and get better in a way that's safe with fewer infections, fewer falls, and also provide an environment both for patients, families and the people who care for them that is more compassionate and user-friendly. As Griffin, Holy Cross, Woodwinds and many other hospitals have demonstrated, evidence-based and patient-centered designs are making a big difference in safety, quality and efficiency across the country. Again and again we will see the power of evidence-based design to make hospitals new and old, more efficient and financially sound. Its effect on these institutions has been both broad and deep. Evidence-based design is more than environmental psychology. It extends into literally everything the organization does. The return on investment has been impressive. The outcomes have improved not only the health of patients, but the financial health of the hospitals themselves. In the 70s and 80s, Griffin was viewed negatively by our competitors, viewed negatively around the state. We had the oldest physical plant in the state. We weren't recognized for any particular centers of excellence. Having difficulty maintaining market share, or having difficulty recruiting physicians and staff. Just one-third of the residents in the community we serve said they would avoid Griffin Hospital if they could. A key force in changing Griffin's space and culture was an organization called Plain Tree. Plain Tree was started by a patient actually almost 30 years ago. And this was a patient, Angela Cateriott, who was hospitalized for about a week. Her experience was horrible, and she talked a lot about the built environment, how sterile it was, how institutional it was, how impersonal and dehumanizing that environment was. Griffin Hospital embodies the principles of Plain Tree, music and visual arts, views of nature, nurturing personalized care, education of patients and families, and including families in care, nutrition for the body and soul, massage and complimentary therapies, and a home-like non-institutional design. In the early 90s, the first challenge was to find an architect who understood such a radical departure from traditional design. We didn't find architects that understood this. We created them. We described the kind of feedback we were getting from patients. What our staff was telling us about what they needed to be able to meet the patient's expectation. And then we took them around the country, and we took our architects and laid them on stretchers and wheeled them through hallways. One of the misconceptions about evidence-based design is that it is prohibitively expensive. Griffin had few reserves and a small endowment, and state regulators demanded that the cost of new construction must not exceed the cost of previous, more traditional hospitals. Many of the fitness finishes that are produced for hospitals carry a produced-for-hospital cost. And by looking at alternative suppliers of such things as handrails, of carpeting, of looking for small manufacturers of furniture, we were able to create this institution well within those parameters. Griffin gave a high priority to reducing stress for staff, families and patients by controlling light and noise. The hospital uses a sophisticated mix of different kinds of light, strong localized light for workspaces, indirect and accent lights for hallways, and natural light from windows and skylights. We find that lighting can provide a much more inspirational contribution to the healing environment. We have the raw evidence that lighting actually contributes to accelerated healing. A recent study in another hospital found that patients exposed to more sunlight experienced less perceived stress, less pain. Took 22% less analgesic medication per hour and had 20% less pain medication costs. When we did focus groups early on with patients, their biggest complaint was noise in hospitals that prevented them from getting well, from resting. Our environment is extremely quiet. We average 10 overhead pages a day as we provide radios and beepers to all staff. Padded carpets were used to cut down on noise. We actually have an antimicrobial treatment in the carpeting. We looked at what's called a moisture impervious back so that if something were to spill in the carpet, we can actually extract it out. At other hospitals, several studies of infants and neonatal intensive care units found that higher noise levels decrease oxygen saturation, increase blood pressure, raise heart and respiration rate, and interfere with sleep. Two of Griffin's biggest design challenges were what to do with the typical large high-traffic nurses station and how to make room for families in the intensive care unit. Griffin's response to the centralized nurses station was to get rid of it and substitute spacious general work areas and individual stations called pods. They're like six mini nurses stations. Everything is right here. Your meds are in this drawer, your charts are over here, and basically your nurses stay here except for breaks. Patients really get very, very close and not afraid that call lights won't be answered. The staff, their initial reaction was, oh my gosh, if you put me that close to the patients and they can see me, they're going to be calling me all the time, I'll never get my work done. In reality, what happened was when the patients could look out and actually see a staff member, their anxiety level went way down and they actually recorded a 40% reduction in call button pressing. Many other hospitals have had similar results. The Center for Health Design's Pebble Project has dozens of participating hospitals which have agreed to measure the results of evidence-based design. Methodist Hospital in Indianapolis reports that better patient room layouts, equipment integration and other design features in its cardiac intensive care unit have helped push patient transfers down 90%. With decentralized nursing stations which allow better observation, patient falls were down 75%. Griffin's intensive care unit is one of its most innovative designs. The critical care unit as a very unique design is built in a horseshoe shape unit with a family visitor corridor, the outside ring of that horseshoe, and patient earns the inner piece of that horseshoe. In a professional corridor on this side, on the outside corridor there's a number of family launches that contribute, we believe, to patient safety because they directly involve the family in access and communication to the patient with the professional staff. Griffin's designers made another unusual choice. They put bathrooms with wide doors in the ICU. That makes a wide opening, it's handicapped accessible, it certainly increases patient safety because ambulatory patients can go to the bathroom with a wide enough door to be assisted by the nurse. The other advantage, certainly, is the nurse that enters the room can dump patient waste in the bathroom, use the sink in the bathroom to wash, which enhances patient care but also contributes to reducing the potential for infection. Griffin is well aware that a good hospital must be both technologically advanced and user friendly. To have a lovely atmosphere without a safe patient experience is somewhat empty. In a time when medication errors are making national headlines, Griffin's pharmacy robot boasts a 99.5% accuracy rate, much better than systems which are not automated. Other hospitals are also finding designs that combat medical errors. In the Barbara N. Carmanos Cancer Institute in Detroit, a 30% reduction in medication errors was achieved through increased space and relocation of their medication room, improved organization of medical supplies, standardized visual cues, and acoustical panels which decreased noise levels. Griffin has been a long road from a hospital teetering on the brink of extinction to a model facility visited by hundreds of health care planners and designers from around the world. We have been for eight years in a row one of the 100 top best places in the United States to work by 4 to 500 magazines. Last year at Griffin we had 7100 applicants for 160 open positions. Griffin is currently building a new cancer center and the fundraising is going well. In seeking funding in fact it's easier when you're innovating to be able to show somebody and you get the wow factor. You know people look at it and say I want to be associated with this. As in every hospital it is the patients and families who have the final word and determine the future success of the institution. The first thing I said when I walked in, so quiet. And they have so much for you here, like that kitchen down there. Satisfying patients makes good business sense because patients vote what they're feeding and they're going to choose a hospital where they feel supported. Nice having you. Thank you. And where they have an experience that meets or exceeds their expectations. It is absolutely essential that when we're talking about building a new hospital or a major renovation that the organization can crystal clear about why are they doing and what do they believe and what are their values. What are they trying to talk? We started with a mission. Our shorthand is we want to be most trusted. And we think that means we have high quality services, the services the community most needs. We make them available to everybody irrespective of their ability to pay. That we also have an abiding interest in research and education. That we worry about the community's health even when they don't come here. And that when they do come here they get a gracious and caring experience. The Holy Cross facility renovated and expanded in the 1960s stood squarely in the way of this mission. A good design in its time, it now faced the need to serve more patients and could not live up to modern hospital standards. That introduction of that concourse not only allowed light to come in gave us an opportunity to focus all that on a healing garden, outdoor indoor space. But it also gave us a chance to reorganize the entire circulation in the hospital so that the general public and the non-patient traffic was moved to the front of the building to sort of bring openness and the outdoors to the complex. No one wants a woman in labor or the family of a patient in intensive care to get lost in a hospital. Poor way finding raises anxiety, makes patients late for appointments and waste staff time. A study at Emory University found that doctors and nurses were wasting 4,500 hours a year giving directions to visitors. So the Holy Cross design team spent considerable time on way finding. They provided valet parking and personal greeters at the entrance. To the right is the maternal and newborn center. The elevators marked by a tiled archway and down the hall a chapel and meeting and teaching spaces. Along the new concourse are registration and various outpatient units. Research shows that staff fatigue leads to medical errors and low morale, undermines safety and quality and can cause high staff turnover. So the design team at Holy Cross worked to eliminate bending and reaching and minimize walking by placing supplies where they are needed. Most of the plugs and hoses were low down at need level. We with the staff worked out a system where our headwalls are basically all at about shoulder level so there's very little leaning over it's much easier on people's extremities. There's less tubing and it's easier to follow the tubing so it makes it safer for the patient. Nurses also suggested double cushioned laminated floors which reduce back fatigue. We went to having multiple pharmacy dispersal units which we called the pixus. And we ended up with two so that the nurses did not have to walk all the way up and down the hall. Delay and distractions in entering data contribute to errors which kill or injure thousands of patients nationwide. So Holy Cross provides nurses with cows or computers on wheels which allow the immediate entry of data. Following American Institute of Architects guidelines Holy Cross converted as many of its double rooms as it could to single rooms. You don't get an infection from your roommate that family members are more likely to be present therefore there are fewer falls and that the rooms themselves are less cluttered so there's less stuff on the way from the bed to the bathroom and that combination means that you reduce falls and reduce infection Those are very big safety issues. A couple of weeks ago I had another hospital stay just over night and it wasn't a double room. She could hear some of the questions the doctors were asking. With the private room it takes away all that anxiety of helping you I think well for me to help me through my recovery. Allocating space for things like patient and staff education is an important part of designing for quality. Improving staff recruiting and retention. If there's a Monday morning conference we can be there at 7.30 educational meetings, CME courses. If there is inadequate attention to the care and feeding of the people who work for you then I think you end up in a death spot quite frankly because in a world in which particularly the well-insured patients have choices then they are going to vote with their feet and go to institutions where they feel that they're being cared for and that the environment supports that care. Design matters. Staff at another one of the Pebble Project hospitals the Parrish Medical Center in Titusville, Florida found in their new building that access to natural light, improved airflow separation of public and patient transport areas and a home-like patient room design dramatically improved their work life and in turn the care they provided. Staff turnover dropped from percentages in the low 20s to 13% in one year. One of the strategic decisions we made was that we were going to even with tight space create physician office space and we did that because we believed that a convenient opportunity for physicians to practice close to the hospital would be an antidote for what we've seen happening which is less physician involvement in hospital affairs. The improvements resulting from renovation at Holy Cross have been substantial. We're now the second largest hospital in the state in terms of discharges. We had almost a 10% growth rate in our inpatient volume last year. Another welcome result was an increase in fundraising. We were able to raise over nine million dollars but probably more importantly we made a change in what we call the culture of philanthropy at the hospital. We've now created a foundation. Given its space limitations, Holy Cross has achieved significant improvements and both patients and staff have noticed the difference. The staff was always very attentive just like being at home because you didn't have all that bulky equipment everywhere. To think that we have this wonderful facility in our backyard, it's just wonderful. Holy Cross has done a wonderful job at creating a very nurturing and warm environment. You don't feel like you're in a cold institution. Oh, the artwork, it's fantastic. I think for years we've been a very paternal industry. We always say we know what's best for you but this was a rather unique experience where we could go out and ask the consumers what kind of a healthcare experience would you like? People tell us all the time when they come through the doors it doesn't look like, sound like, or smell like a hospital. You could go to one of the day rooms. Beautiful kind of lounge areas for both patients and family. You gotta wash your hands first, okay? You have the gigantic windows with the light coming in and have the natural scenery to look out there. Here you get your own private birthing suite with a gigantic bathroom and a tub that you can just relax in. You don't have to worry about other visitors coming in that aren't yours. At Woodwinds, the environment is part of the treatment. Our evidence has shown us that the environment controls the brain and the brain controls healing. Therefore it behooves us to alter our healthcare environments so that we can do everything we can to improve healing. Roger Ulrich studied the outcomes at another hospital for patients in rooms with different views. If they had the window view of nature and if one carefully controlled for other factors the good views seemed to improve their emotional states, reduce their stress. They took fewer strong pain drugs for pain. They have fewer minor complications such as persistent headache or nausea requiring medication. Congratulations! And they stayed in the hospital less time. In a renovated nursing unit at St. Alphonsus Regional Medical Center in Boise, Idaho, large private rooms, carpet in hallways, acoustical tiles on walls and ceilings, and relocated machinery brought noise levels down substantially and improved the quality of patient sleep from 4.9 to 7.3 on a scale of 0 to 10. It is almost always very quiet at Woodwinds. More quiet means better healing. In another study, researcher Roger Ulrich studied the effect of changing the ceiling tiles in a coronary intensive care unit. If the high performance sound absorbing tiles were in place and controlling for all other factors such as acuity of patients, bed occupancy and so on, we learned that patients treated during the better acoustics, they were less stressed including they had lower blood pressure, they slept better, they judged the quality of care they received as much better, and they were at substantially less risk of being re-hospitalized. It's really often simply putting ourselves in the place of the patient and understanding what it's like to lay in bed at night, sick, frightened in an unfamiliar place and then have alarms going off. As at Griffin and Holy Cross, elements in the design encourage patients to be active participants in their own care. People who feel a greater sense of control often heal better, feel better, are more empowered to be involved in their own care. The ideal healing environment, you would want as much control as possible to be right there at the bedside. We disable people by making them helpless in an environment. The environment needs to do the opposite. It needs to make them capable and confident about their own self-care. If I'm surrounded with an environment that makes it feel like yes, you're important and we care about you, that keeps me responsible, that keeps me doing my best to help the process. Like the views of nature and natural light, rich colors and positive diversions at Woodwinds are not just decorations. They are part of a carefully thought-out strategy for reducing stress and anxiety. Color is cheap and you can create such a robust environment with such vitality. Positive diversions is another area and these are anything from gardens to aquariums, things that people can look at five or ten minutes and forget about your pain or your anxiety. The Woodwinds design team knew that they were creating a healing environment, not just for patients, but for staff. One of the happy sides to this idea of evidence-based design is that unlike some calls for change in health care, it really thoroughly unites the interests and the life experience of the workforce in health care with that of the patient. Well, we'll see and we'll make sure that you're okay before you go to therapy. Okay. The medical errors which plague hospitals are often blamed on staff when in fact they're often the result of bad design. People that are at the front end or at the sharp end of patient care sort of inherit the sins of omission and comission of everybody else in the health care system. How long has that provider been up on his or her feet? Is the noise level stressful? Now what we're going to do is we're going to lift you up. Alright. Nurse work-related injuries are unfortunately very, very common. One of the challenges we have today is patients of size with lifting and turning. These can be devastating injuries that will end a career or result in the nurse being off work for long periods of time. One study of a nursing home found that the use of lifts and walking belts decreased the incidence of staff back injuries by more than 40%. Woodwinds has won many awards since its opening. Fundraising has grown and the bottom line is healthy. Well, when I think about Woodwinds and what we created here I'm obviously very, very proud. But it is the successes with the staff and the patients that they value most. Recruitment efforts started in 2000. We had nearly 4,000 people applied for 400 positions. It's the philosophy of administration that says we value you as an employee and we give you an environment that's conducive to working in. Our patient satisfaction scores have been excellent. With our 8-bed ICU, one would think small ICU, soft environment that our outcomes would not be as good as a tertiary care hospital. We're leading the pack. And I say, okay, who's a competent surgeon who I can get at Woodwinds because to me the combination of the physical facility and the complementary therapies and the attitude of the staff just make all the difference in the world for my healing. We all know what kind of hospitals we don't want. Couldn't see the outdoors. I didn't know whether it was day or night because the toilet was in the way. Noise from the nursing station. All the things we read about were all there. And I came out of that traumatized. Family visiting hours were generally maybe one hour twice a day. That was it. And that my mother died alone and none of us could be there with her. The evidence now is that we know that the built environment can be a tool that can save lives and that can make the experience of families, of patients and of caregivers much more effective, much safer, much less stressful. How can CEOs make use of this powerful new tool? For hospitals not undertaking major building projects, there are many low-cost interventions that should be implemented. Handwashing facilities in every room. Reducing noise. Providing music that patients can select to reduce anxiety. Adding inexpensive technology to reduce unnecessary, costly patient transfers. And improving way-finding systems to reduce confusion and stress. For those planning major construction, the opportunities and the responsibilities for the CEO are much greater. First, become a committed champion and lead your organization on the path to superior outcomes from effective designs based on credible research evidence. To me, the role of a CEO is all about leadership and establishment of a vision and communicating that vision both in words and actions over a long period of time. I think it's also a recognition that you can't do it alone. There's a huge amount of teamwork that has to occur. CEOs and their team should choose architects, designers and consultants who have a proven track record in applying evidence-based design in their projects. It's not just the design professionals who are coming with their expertise. It's also understanding and users' needs, you know, bringing in the nurse professionals and the clinicians and the patients. If CEOs wish to investigate evidence-based design further, they can take advantage of the growing number of conferences, workshops and webinars in the field. And they should develop sound methodologies to identify, assess, implement and measure the value of evidence-based designs. What kind of results can CEOs expect? The business case for evidence-based design grows stronger every year. Recently, a leading market-rater issued a report predicting that a disciplined operational plan combined with evidence-based design will be a differentiating factor in rating hospital credit in the future. Well, we've had tremendous growth since we opened the new facility in 2000. In fact, we've grown by over 42% since we opened. So we're about one and a half times the size that we were just a few years ago. Using real-life data reported by hospitals taking part in the Center for Health Design Pebble Project, a group of researchers imagined a fable hospital, a typical new 300-bed hospital budgeted at $240 million. Then they added an additional $12 million for things like single-windowed variable acuity rooms, additional handwashing capability, decentralized nursing stations and computerized order entry. They added HEPA filters for all rooms, double-door bathroom access, healing art, music and gardens, consultation spaces, a patient education center and staff support facilities. The projected results over the first year were surprising. Reductions in patient falls by 80% would save $2.5 million. A drop in patient transfers by 80% would result in a cost saving of $3.9 million. Fewer nosocomial infections would save $80,640. Reductions in per-patient drug costs by 5% associated with positive distractions would lead to a saving of $1.2 million. Reductions in nursing turnover from 14% to 10% would result in a saving of $164,000. Increasing market share by 1.5% would increase net revenue by $2.2 million. And finally, philanthropic contributions would rise about $1.5 million. Total savings and revenue enhancements from a $12 million investment, $11.5 million in the first year, with significant further savings over the life of the building. If you do it well, it has a positive impact for 50 years. If you do it poorly, it jeopardizes the care that you're providing to patients and actually can put the hospital in jeopardy.