Blair L. Sadler

The case for building better hospitals is stronger than ever.




By Blair Sadler

Editor's note: A version of this article was first published in Modern Healthcare, October 18, 2004.

Building a new facility is usually the biggest capital investment a hospital CEO and Board of Trustees ever will make. Hospitals will spend more than $12 billion this year on new construction, and by 2010 spending on new hospital construction is expected to increase to $16-$20 billion
annually. With so much at stake, the time is right for hospital leaders to spend a little more money to build not just a new hospital, but a better hospital—one that actually will save significant dollars in the long run.

It is well-documented and widely known that hospital buildings are too often dangerous and stressful places for patients, families and staff. According to the Institute of Medicine, medical errors and hospital-acquired infections are among the leading causes of death, each killing more Americans than AIDS, breast cancer or automobile accidents. Payers, employers, governments, accrediting bodies and consumers themselves are placing increasing pressure on hospitals to become safe and effective places to work and heal.

Just as healthcare is increasingly moving toward "evidence-based medicine," there has been an explosion of "evidence-based
design"—rigorous research studies linking the physical environment of hospitals to clinical and satisfaction outcomes for patients and staff. More than 600 published evidence-based design studies have been identified by The Center for Health Design. These studies are summarized in a report published by The Center in September that was funded by the Robert Wood Johnson Foundation. In the report, authors Roger Ulrich, Ph.D., of Texas A&M University and Craig Zimring, Ph.D., of Georgia Institute of Technology conclude that "the scientific literature is confirming that conventional ways that hospitals are designed contribute to stress and danger, or more positively, that this level of risk is unnecessary: Improved physical settings can be an important tool in making hospitals safer, more healing and better places to work."

Based on this research, there are several design innovations that every hospital involved in a building project should undertake immediately: (1) build larger single-bed rooms and significantly reduce hospital-induced nosocomial infections while including spaces for patient, family and staff activities, and in-room procedures; (2) make rooms acuity adaptable by standardizing shape, size and headwalls, thus reducing unnecessary, costly and dangerous patient transfers; (3) include double-door bathroom access, reducing patient falls and staff injuries; (4) install hand hygiene dispensers in each patient room to reduce staff-to-patient transmission of pathogens; and (5) provide positive distractions through appropriate art, restful views and access to nature, thus relieving unnecessary stress and improving patient satisfaction. There are several others.

But, in the current healthcare economic environment with capital so difficult to obtain,
hospital management might ask: "Are these good ideas affordable? Is there indeed a business case for building better hospitals?" The answer is yes. Based on published evidence and the experience of pioneering organizations using evidence-based design to construct new facilities, six individuals affiliated with The Center for Health Design (CEOs, architects, a business professor and a futurist) analyzed the data and designed a hypothetical Fable Hospital. It is a Fable because it has not yet been built, but it could be at any time by someone—starting tomorrow. Will that someone be one of your clients?

The Fable Hospital is a 300-bed replacement hospital costing $240 million—the average cost of building a conventional hospital today. In the Fable, a courageous CEO decides to include all the proven design innovations mentioned above and others proven to work. After detailed analysis, he concludes it will require a modest one-time cost. However, to his surprise, the analysis also shows significant operating cost savings and revenue increases in the first year alone (coming from a reduction in patient falls, fewer patient transfers and reduced drug costs, as well as measurable increase in market share). Most of these savings recur year after year, making it a superb long-term investment.

Armed with this evidence, the CEO and the Board of Trustees decide to proceed and convert the Fable idea into reality. To do so, they: (1) formally incorporate evidence-based design into their vision of the project; (2) select an architect who is fully
conversant in the latest design research; and (3) hire researchers and advisors who develop easily usable instruments that measure the impact of their decisions, and publish their results.

Hospital CEOs have an extraordinary opportunity and a serious responsibility to truly build better hospitals—ones that facilitate physical, mental and social well-being, and productive behavior in their occupants. Also, through measured superior performance we can actually improve our organization's financial results.

The bottom line is that most hospital boards and executive leaders have only one or two opportunities in their professional lives to create a permanent legacy that can transform
their organizations and communities. Building a better hospital is an opportunity that should not and must not be wasted. The evidence for making an investment in facility excellence no longer can be ignored. And the lesson for all healthcare organizations is clear: Provide a built environment that is welcoming to patients, measurably improves their quality of life, and supports families and employees—or suffer the economic consequences in an increasingly competitive and demanding economic

  • Blair L. Sadler is president and CEO of Children's Hospital and Health Center in San Diego, CA, and a member of the Board of Directors for The Center for Health Design. He is the co-author of "The Business Case for Better Buildings," the lead article in the Fall 2004 issue of Frontiers of Health Services Management.