Connecting the Dots

What do evidence-based design, improved outcomes, and the ACA have in common?

Each year at the Healthcare Design Conference there is a pre-conference session dedicated to coaching healthcare systems professionals, providers, design practitioners, educators, contractors, and other key players interested in learning or further developing an evidence-based design (EBD) process. The recommendation is always to start with what you know and grow the process appropriately depending upon the project and desired outcomes. Although the process is consistent, the priorities and benchmarks may vary greatly across project types.

However, in evaluating opportunities when establishing baselines for outcomes—which has always been a tenet of EBD—there is the necessity for measuring these improvements because they are tied to reimbursements under the Affordable Care Act (ACA). This is an important intersection between EBD and the ACA because evaluating these priorities can result not only in increased efficiencies and reduced costs, but also improved medical outcomes.

The following three case studies demonstrate an EBD approach based on varying goals and project requirements, and they also take new ACA requirements into consideration.

princeton healthcare system
In May 2012, Princeton HealthCare System (PHCS) opened a new 238-bed, 575,000-square-foot, non-profit acute care hospital as part of the University Medical Center located in Plainsboro, N.J. This Pebble Project consisted of a patient bed tower, a diagnostic and treatment building, an administration and education building, and an onsite co-generation plant that supports the hospital. The Center for Health Design utilizes the Pebble Project to assist clients with utilizing research to not only make informed decisions, but also to provide a framework for completing benchmarks and research within a healthcare setting to sustain continued improvement.

The vision for this project was to build one of the finest hospitals in the U.S. that would support and encourage outstanding clinical care, provide the most-advanced technology, and demonstrate commitment to the community by incorporating sustainable design and function.

Barry Rabner, PHCS president and CEO, along with the trustees hired Navigant to help manage the project and two architectural firms, HOK and RMJM Hillier, as part of the design team. As a participant in the Pebble Project, the decision-making process was led by the program’s guiding principles, which include the use of EBD for enhanced patient safety; the development of environments conducive to healing; ranking in the top 10 percent of U.S. hospitals for patient satisfaction; embracing patient-centered care concepts; and optimizing operational efficiency with related cost reductions. Flexible design was also adopted with the unusual caveat that included building 150 percent of the current project need to allow for expansion.

Under Rabner’s direction, every detail of the new hospital—from safety features to patient and family comfort to maximizing staff efficiency—was thoroughly researched. In working with the Center for Health Design, there was a review of approximately 1,200 articles of design research, feedback from staff and administration at 15 other hospitals, and multiple focus groups of stakeholders and patients.

yale-new haven hospital
Likewise, Salvatore Associates and CAMA, Inc. recently completed a new Adult Emergency Environment of Care for Yale-New Haven Hospital located in New Haven, Conn. It utilized an interdisciplinary design team that was guided by the following EBD objectives:

  • Reduce patient and visitor stress
  • Reduce wait times and improve flow
  • Improve staff sightlines—both from a security and clinical care point of view
  • Capture natural light and views of nature at an urban edge

These goals were met by utilizing an open clinical core design intervention that contributes to improving communications between caregivers by:

  • Providing clear visual communication throughout the unit
  • Enhancing care team verbal communication in care stations
  • Creating centralized, private, staff consult area (glazed)
  • Reducing visual chaos and stress for caregivers and patients

A chair-centric care delivery is utilized for triaging patients at Emergency Severity Index (ESI) Levels 4 and 5. Preliminary findings indicate the approach will help meet ACA requirements by:

  • Reducing patient stress, medication levels, and required square footage
  • Increasing patient satisfaction and throughput

Further, security and privacy at the entrance is accommodated upon entering the new Adult Emergency Environment of Care that achieves the following:

  • Calming and restorative powers of nature and natural light
  • Private areas away from others to have more discrete conversations with caregivers
  • Planting areas built into the casework
  • Art glass used to screen patients from general view

unitypoint health
When faced with the challenge of integrating a behavioral healthcare setting in the Emergency Department at UnityPoint Health located in Rock Island, Ill., CannonDesign hypothesized that the creation of a Crisis Stabilization Unit (CSU) within a “living room concept” as an interventional strategy would provide a higher quality of care to patients, thus helping to ensure desirable outcomes under the ACA.

The CSU would assist in the staff’s ability to quickly consult and treat a diverse set of patients with behavioral health concerns entering the ED. The “living room” or patient lounge within the CSU would be a space where patient-peer counseling could occur when appropriate, along with caregiver and family care.

With a projected increase in behavioral health patients at the UnityPoint Health ED, additional stress is placed on the hospital to provide quality treatment in a safe and effective manner. The goal of the new ED is to utilize the facility design including safe rooms and the crisis stabilization unit, along with a new model of care that positively impacts patient average length of stay, readmission rates, and patient and staff safety. The team is conducting a multiyear research study that will develop and test whether these interventions are linked to improvements in patient and staff satisfaction, quality of care, safety, and legal and financial targets. Data will be compared pre- and post-occupancy through paired t-test analysis of hospital metrics, observation, and qualitative analysis of staff and patient focus groups.

As these case studies illustrate, utilizing an EBD approach can increase efficiency and reduce costs, but most importantly, inform the care model and improve patient outcomes.

Jane Rohde, AIA, FIIDA, ASID, ACHA, AAHID, LEED AP, is the founding principal of JSR Associates, Inc., located in Ellicott City, Md. She champions a global cultural shift toward de-institutionalizing senior living and healthcare facilities through person-centered principles, research and advocacy, and design of the built environment. Clientele includes non-profit and for-profit developers, government agencies, senior living and health care providers, and design firms. Rohde speaks internationally on senior living, aging, healthcare, evidence-based design, and sustainability. For more information or comments, please contact her at

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