Evidence-based design:Recent developments

Roger S. Ulrich, Ph.D.Center for Healthcare Building Research

Department of ArchitectureChalmers University of Technology

Forum -- Hälsofrämjande vårdmiljöer Skånes universitetssjukhus, Malmö

Design/research questions: • Is the ‘attractiveness’ of

health- care interior spaces important?

• Does attractiveness affect patient outcomes?

BACKGROUND THEORY and RESEARCH: Why room attractiveness should matter

• Study methods: Participants (who were not patients) were assigned to either a ‘beautiful’ room (well-decorated and well-lit), average room, or ‘ugly’ room (undecorated walls and poor lighting)

• While seated in the rooms, participants were asked to make judgments or evaluations about several persons shown in photos

1. The ‘Beautiful Room Effect’ (Maslow and Mintz, 1956)

• Findings: Participants in the beautiful room gave the most positive evaluations of the persons in the photos

• Participants in the ugly room gave the most negative, unfavorable judgments

‘Beautiful Room Effect’ -- continued (Maslow and Mintz, 1956)

Implication: Implication: An attractive room may An attractive room may produce a more positive emotional state produce a more positive emotional state and judgment disposition that generalizes and judgment disposition that generalizes to more favorable perceptions of other to more favorable perceptions of other persons in the spacepersons in the space

• Consistent with Maslow and Mintz’ early research, studies have found that attractive patient rooms and clinic waiting rooms increase patients’ perceived quality of healthcare staff For example, doctors are judged to have

more skill and knowledge when patients are examined in attractive rooms, compared to when the same doctors give similar treatment in unattractive rooms (Swan et al., 2003; Becker and Douglass, 2008; Becker et al., 2008)

‘Beautiful Room Effect’ -- continued

BACKGROUND THEORY and RESEARCH: Why room attractiveness should matter

2. Service Quality Theory and Research (Parasuraman et al., 1985; Berry and Bendapudi, 2003)Much research has shown that patients base their judgments of satisfaction and quality on information which they can personally perceive and evaluate, and which provides them with concrete, meaningful information they understand

provides tangible and meaningful evidence (Berry and Bendapudi, 2003)

But healthcare is a highly complex and technical service. Many aspects remain unknown to patients or are only vaguely perceived and are not understandable.

These aspects have little or no impact

on satisfaction or quality judgments

Examples of abstract or unknowable factors include the quality of care processes, and levels of clinician training and experience

Service Quality Theory and Research -- continued --

Compared to abstract or unknowable technical aspects, environmental factors such as noise or privacy are easy to perceive and understand, and provide meaningful information that strongly impacts patient satisfaction

Other perceivable and meaningful

information comes from staff behavior

Service Quality Theory and Research -- continued

The attractiveness or comfort of a hospital waiting room, for example, is directly perceived and understandable evidence, and therefore can be expected to affect patient satisfaction

Service Quality Theory and Research -- continued

Research findings: Consistent with service quality theory, a growing amount of research has shown that attractive waiting rooms increase patients’ overall satisfaction with care

Study:Effects of Waiting Room Comfort on Overall Satisfaction with Care(Hospital and Family Medicine Clinics)

From: K. M. Leddy (2005)Press Ganey Associates

Based on data from 1,201,559 patients treated at 4,392 medical practice offices throughout U.S. (January - December, 2004)

<10 10 to 14 15 to 19 20 to 30 >30

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Very GOODVery GOOD

FAIRFAIR

Very POORVery POORPoor

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Satisfaction with Care Experience by Amount of Time Spent in Waiting Room and Comfort of Clinic Waiting Room

R. Ulrich. Data source: Press Ganey, 2005

+117%+117%

Emergency department waiting room where stress, long waits, and low satisfaction are problems

Providence St. Vincent Hospital

Portland, OregonEmergency Department

Waiting Room - with garden views to reduce

stress, aggression, increase satisfaction

Design: ZGF and Robert Murase

More research needed on attractiveness

Research has not yet clearly identified what attractiveness is Some studies use terms such as “comfort” and

“attractiveness” interchangeably with defining themResearch has not yet identified for

designers and healthcare managers the most important and cost-effective design factors for achieving attractiveness

Other research suggests that many architects judge attractiveness differently than the public

Lighting quality, including daylightPresence/absence of appealing art

or wall decorationComfort and quality of seating, and

whether chairs are movableAcoustics (probably)Crowding (probably)Other (very likely)

Given limits in current research, what design factors may affect attractiveness?

Attractiveness remains a vague concept, but research suggests it is important to patients and families (and staff)

Whatever attractiveness is, research

implies it should be given considerable attention or priority

Many architects perceive attractiveness differently than the public, indicating the need for designers to listen carefully to patients and other groups

Attractiveness: conclusions

Part 2:Comments on the report from HTA-centrum (Sahlgrenska) titled:

“Enklerum eller flerbäddsrum på sjukhusavdelning”

Moore et al (2008): exposure to one room-mate with MRSA increased risk by 20 times (Infection Control & Hospital Epidemiology)

McFarland et al (1989): C. difficile risk increased by 73% (New England J. Medicine)

Chang and Nelson (2000): C. difficile risk increased by 86% (Clinical Infectious Diseases)

Byers et al (2001): VRE risk increased by 149% (Infection Control & Hosp. Epidemiology)

Research examples:

Increased infection risk from having one roommate with a positive culture

Implication:Implication: providing single rooms for providing single rooms for patients substantially reduces risk of patients substantially reduces risk of acquiring an infectionacquiring an infection

STUDY: Converting an intensive care unit to single rooms substantially reduces infection

• Study site: 25-bed intensive care unit before and after renovation to all single rooms (Well-controlled, rigorous research design.)

• Main findings: C. difficile decreased 43% MRSA decreased 47% Overall average length of stay decreased

10% (all patients in intensive care)

(Teltsch et al. 2011, Archives of Internal Medicine)

STUDY: Exposure to hospital roommates as a risk factor for healthcare-associated infection

• Study population: 94,784 adult hospital patients in Canada

• Main findings: The number of roommate exposures per day

was significantly and strongly associated with MRSA, VRE, and C. difficile infection

Having one roommate increased infection risk by 11%, even if the roommate was not infected. Exposure to 6 roommates increased risk by 87%.

(Hamel, Zoutman, and O’Callaghan, 2010)

Ben-Abraham, Keller, Szold, Vardi, Weinberg, Barzilay, et al. (2002). Journal of Critical Care.

Berild, D., Smaabrekke, L., Halvorsen, D. S., Lelek, M., Stahlsberg, E. M. & Ringertz, S. H. (2003). Journal of Hospital Infection.

Byers, Anglim, Anneski, Teresa, Gold, & Durbin (2001). Infection Control and Hospital Epidemiology.

Cheng, Tai, Chan, Lau, Chan, et al. (2010). BMC Infectious Diseases. Gastmeier, Schwab, Geffers & Ruden (2004). Infection Control and

Hospital Epidemiology.Jernigan, Titus, Groschel, Getchell-White, & Farr (1996). American

Journal of Epidemiology.Wigglesworth & Wilcox (2006). Journal of Hospital Infection. Zhou et al. (2008). Infection Control and Hospital Epidemiology.

Examples of studies reporting that single rooms reduce MRSA, VRE, and/or C. difficile

C. difficile Infection Control Practice Guidelines

PIDAC 2006 Best Practices Document for the Management of Clostridium difficile Prevention in All Healthcare Settings

-- All patients suspected of having CDAD should be placed in a single room with dedicated toileting facilities, if available (7).

CDC 2007 Guidelines for Isolation Precautions: Preventing Transmis-sion of Infectious Agents in Healthcare Settings

-- In acute care hospitals, place patients who require contact precautions in a single-patient room when available (84).

SHEA 1995 Clostridium Difficile-Associated Diarrhea and Colitis

-- Isolation of patients with CDAD in private rooms is recommended if private rooms are available . . .

AIA 2006 Guidelines for Design and Construction of Health Care Facilities

-- In new construction, the maximum number of beds per room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement.

Single Rooms Enhance Family Presence, Staff Communication, and Privacy

(Kaldenburg, 1999; Chaudhury et al., 2003)

Single-bed vs. Multi-bed Patient Rooms (Ulrich, 2004)

SingleSingle Multi-bedMulti-bedHealthcare associated infectionsMedical errorsFallsStaff observation of patientsStaff/patient communicationConfidentiality of informationPresence of familyPatient privacy and dignityAvoid mixed-sex accommodationEnd-of-life with dignityNoiseSleep quality

UK

PainPatient stressDaylight exposurePatient satisfactionChoiceStaff satisfactionStaff work effectivenessReducing room transfersAdapt to handle high acuityManaging bed availabilityInitial construction costsOperations and whole life costs

Single-bed vs. Multi-bed Patient Rooms (Ulrich, 2004)

SingleSingle Multi-bedMulti-bed

Widely held beliefs obstructing adoption of single-bed rooms

• Beliefs are not evidence-based

• Published evidence contradicts these beliefs

• Many patients (up to 50%) like having roommates

• Single rooms prevent visual observation of patients, therefore worsening safety

• Single rooms require much higher nurse staffing levels (41%), greatly increasing costs

Dr. Charles McLauglan in Hospital Doctor (February 2006)Director of professional standards, Royal College of Anaesthetists

“With single rooms, we need state-of-the-art monitoring equipment because we have not got line-of-sight for the nursing staff.”

‘State-of-the-art monitoring equipment’ in a Canadian hospital built 40 years ago

Single rooms designed for high visual accessToronto General Hospital

Line-of-sight monitoring in an open bay

• Studies show that 85%-90% of the time roommates are source of stress not positive social support Stress examples: roommate who is

unfriendly or seriously ill Roommates generate much noise

and reduce privacy Roommate incompatibility causes

many room transfers

Do patients like having roommates?

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Preferences for Multi-bed vs Single Rooms Findings from Two UK StudiesPr

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Single-bedMulti-beds

Adults with little or no experience with single rooms

Patients with experience with both multi-bed and single roomssource: NHS Estates & BMRB, 2002source: Lawson and Phiri, 2003

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Overall Care Satisfaction – Female Patients(after Kaldenburg, 1999-2003)

Key Policy Changes Affecting Financial Outcomes of UK Public (NHS) HospitalsPatient Choice

Payment by results (by quality) Costs of infections, falls, errors, longer

stays paid to greater extent by trusts

Patients can choose where to go for care. Revenues flow with patients.

Two sources of competition: NHS and private providers

Case study: Effects of patient choice on

public and private hospital revenues in one UK health region (2005)

Study:Financial Impact of Patient Choice in the Birmingham and Black

Country Strategic Health Authority (SHA)

MORI Social Research Institute, 2005

Report prepared for U.K. National Health Services (NHS)

Nothing Nothing at allat all

62% 25% Just a littleJust a little

8%A fair amountA fair amount4%

A great dealA great deal

U.K. Public Awareness of Patient Choice(in 2004)

How much have you heard about the patient choice initiative?

0% 10% 20% 30% 40% 50% 60%

Quality ofinformation

Respectful care

Flexibility onvisiting

Niceenvironment

Lower MRSArisk

Single room

How much do you think the private sector is better than the NHS in these areas of activity?source: 1,201 residents, MORI Birmingham SHA study, 2005

Single rooms improve all these outcomes

Comparing persons ‘easy to persuade’ vs ‘hard to persuade’ to choose a private sector hospital Private room is important:

79% of easy to persuade 47% of hard to persuade

Flexibility about visiting important: 91% of easy to persuade 77% of hard to persuade

NHS better Private sector better Neither

Flexibility about visiting

Nice environment

Based on the survey findings, the private sector was estimated to make £35 million in revenues the first year from patient choice in the Birmingham and Black Country area (source: Independent Healthcare Forum)

> SEK 600,000,000 at 2005 currency rates

• The findings are ‘a major wake-up call for the NHS’

• Both primary care facilities and hospitals ‘need to take implications of choice on board immediately’

-- Peter Pilsbury, Director of Strategy, Birmingham/Black Country SHA (in HSJ)

Marketing brochure for two London private hospitals

156 single rooms

167 single rooms

Golden Jubilee National Hospital (NHS)

Glasgow

Increasingly serious challenges from antibiotic resistant infections

Sicker patients (rising acuity)Increasing importance of patient

privacy and dignityPatient choice and satisfactionPayment by results (by quality)More and more emphasis on

patient safety

Major Healthcare Trends in Europe, N. America, and Australia

Everywhere: strong pressures to reduce or control costs but increase quality

Conclusion Concerning the report from HTA-centrum titled: “Enklerum eler flerbäddsrum på

sjukhusavdelning” My opinion is that the report is narrow, does

not use appropriate criteria for evaluating research quality, omits relevant and strong published studies, misinterprets some information, and does not adequately address certain outcomes and healthcare issues of growing and major importance internationally.

Conclusion

The HTA-centrum report is a gift to the private sector, and to those who may believe that many hospitals should be private.

What To Do When A Hospital Has Many Multi-Bed Rooms

• Upgrade ceiling tiles to reduce noise and voice travel, increase privacy Eliminate noise sources

• Convert a patient room to a refuge for privacy and good communication

• Consider installing additional free-standing handwashing basins

• Provide comfortable family waiting areas