evidence-based design: recent developments roger s. ulrich, ph.d. center for healthcare building...
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Evidence-based design:Recent developments
Roger S. Ulrich, Ph.D.
Center for Healthcare Building ResearchDepartment of Architecture
Chalmers University of Technology
Forum -- Hälsofrämjande vårdmiljöer Skånes universitetssjukhus, Malmö
Design/research questions:
Design/research questions: • Is the ‘attractiveness’ of
health- care interior spaces important?
• Does attractiveness affect patient outcomes?
• 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)
<1010 to 14
15 to 1920 to 30
>30
0
10
20
30
40
50
60
70
80
90
100
Overa
ll
Sati
sfa
cti
on
Length of Wait (minutes)
Very GOODVery GOOD
FAIRFAIR
Very POORVery POOR
Poor
Good
Overa
ll
Sati
sfa
cti
on
Perc
eiv
ed
Com
fort
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%+117%+117%
Emergency department waiting room where stress, long waits, and low satisfaction are problems
Providence St. Vincent Hospital
Portland, Oregon
Emergency Department Waiting Room - with
garden views to reduce stress, aggression,
increase satisfactionDesign: 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 them
Research 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”
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?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Preferences for Multi-bed vs Single Rooms Findings from Two UK StudiesP
refe
ren
ce
Single-bed
Multi-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
72
74
76
78
80
82
84
0-17 18-34 35-49 50-64 65-79 >80
Age
Ove
rall
Room
Sat
isfa
ctio
n
With roommate Single room
Overall Care Satisfaction – Female Patients(after Kaldenburg, 1999-2003)
Key Policy Changes Affecting Financial Outcomes of UK Public (NHS) Hospitals
Patient 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)
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