Evidence Based Design

Evidence-Based Design: Application in the MHS
3 August 2007 1 August 2007

by
Eileen Malone Julie R. Mann-Dooks Joseph Strauss

for

HFPA Planning & Programming Division & TRICARE Management Activity PPMD

“We shape our buildings and afterwards our buildings shape us.”
–– Sir Winston Churchill May 10, 1941

Evidence-Based Design: Application in the MHS

TABLE OF CONTENTS
EXECUTIVE SUMMARY ..................................................................................................................... 5 I. INTRODUCTION ............................................................................................................................ 9

II. A BRIEF HISTORY AND OVERVIEW OF EBD ...................................................................... 11 OUR DEFINITION OF EVIDENCE-BASED DESIGN .............................................................................11 THE THEORETICAL LINEAGE OF EVIDENCE-BASED DESIGN ..........................................................11 THE EVOLUTION OF EVIDENCE-BASED DESIGN .............................................................................14
EBD Research, Advocates and Researchers – A Timeline...................................................................14 EBD Resources ....................................................................................................................................17 EBD Practitioners: Health Care Facilities..........................................................................................18 EBD in the Military Health System......................................................................................................19

III. CURRENT COMPELLING EBD SCIENCE .............................................................................. 23 EBD PRINCIPLE 1: CREATE A PATIENT- & FAMILY-CENTERED ENVIRONMENT ............................26 EBD PRINCIPLE 2: IMPROVE THE QUALITY AND SAFETY OF HEALTHCARE ...................................34 EBD PRINCIPLE 3: ENHANCE CARE OF THE WHOLE PERSON (CONTACT WITH NATURE & POSITIVE DISTRACTIONS).................................................................................43 EBD PRINCIPLE 4: CREATE A POSITIVE WORK ENVIRONMENT .....................................................45 EBD PRINCIPLE 5: DESIGN FOR MAXIMUM STANDARDIZATION, FUTURE FLEXIBILITY AND GROWTH ...........................................................................................................52 IV. EBD ACTIVITY CHECK LISTS ................................................................................................. 57 FACILITY LIFE CYCLE MANAGEMENT AND PERFORMANCE MODEL ..............................................57
Strategic and Business Planning..........................................................................................................58 Business Planning................................................................................................................................59 Facility Master Planning .....................................................................................................................60 Transition Planning .............................................................................................................................61 Project Planning ..................................................................................................................................61 Programming .......................................................................................................................................62 Design ..................................................................................................................................................63 Construction.........................................................................................................................................63 Commissioning and Occupancy...........................................................................................................64 Sustainment..........................................................................................................................................64

V. SUMMARY OF RECOMMENDATIONS: A ONCE-IN-A-LIFETIME OPPORTUNITY... 67
Recommendations ................................................................................................................................67 Next Steps.............................................................................................................................................68

ATTACHMENTS.................................................................................................................................. 71 CASE STUDIES: FACILITY TOURS ....................................................................................................73 CASE STUDY: NCA/BRAC MILCON - APPLYING EBD PRINCIPLES ............................................75
EBD Design Principles used in Epidaurus ..........................................................................................75 Single-Bed Inpatient Rooms.................................................................................................................75 Patient and Staff Support on Inpatient Units .......................................................................................75 Other Patient-Centered Concepts Adopted..........................................................................................76

MEMO FROM DR. WINKENWERDER ................................................................................................77 FUTURE STUDY OPPORTUNITIES .....................................................................................................79 END NOTES ...........................................................................................................................85

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Executive Summary

Evidence-Based Design: Application in the MHS

Executive Summary
Introduction Over the past 10 years, Evidence-Based Design (EBD) has emerged as a scientific response to the questions about how the built environment impacts patient, staff and resource outcomes. EBD inquiry has exponentially exploded in the wake of the Institute of Medicine’s benchmark studies about the quality and safety of healthcare delivery in America. Military Health System (MHS) leaders want to understand the emerging science implications with regard to the Department of Defense health care facility planning, design and construction guidelines and then to provide an educational platform for their community. The Army Health Facility Planning Agency, funded by the TRICARE Management Activity Portfolio Planning and Management Directorate, contracted with Noblis (formerly Mitretek Systems) to conduct a research study as the basis for educating military healthcare planners. This report documents the results of this study, which includes an extensive EBD literature review (organized around the Department of Defenses’ EBD principles and goals), recommended EBD features and responses, and future study opportunities. In addition, EBD activities were identified for each phase of the Facility Life Cycle Management and Performance Model as a framework to facilitate the integration of EBD science across the continuum of medical construction projects and healthcare facility maintenance activities. Definition EBD represents an emerging body of science that links elements of the built environment with patient, staff and resource outcomes. The goal is to create a healing environment – one that is safe, comfortable, and that supports the patient, the patient’s family, and the staff. Successful EBD depends on transformational leadership and culture and, frequently, a reengineering of clinical and business processes. While this synergistic response sometimes makes it difficult to completely ascertain the impact of the built environment alone in improving outcomes, there is strong and growing evidence that the application of EBD principles and features has a positive impact on patient, staff and resource outcomes. Overview & History EBD has evolved from the disciplines of evidence-based medicine and evidence-based practice. More healthcare evidence is collected every year, as the concept of quality in healthcare has come to the forefront of the American consciousness. Multiple groups have been formed to study EBD and augment the literature with new research and conclusions. The Center for Health Design is the largest advocacy group, and provides an excellent website with a compilation of resources on the state of the science. Professional design standards, such as the AIA Guidelines and the DoD Space Planning Criteria, have begun to reflect advances in EBD research.

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The MHS has several concurrent ongoing studies that are relevant to EBD and has applied many EBD concepts in the programming, planning and now design of the Base Realignment and Closure Act (2006, BRAC)-generated facilities in the National Capital Area: the New Walter Reed National Military Medical Center at Bethesda and the New Community Hospital at Fort Belvoir. EBD Study The MHS has embraced five EBD principles, with attendant goals and desired outcomes as listed below. These principles served to focus the EBD literature review for this Study. 1. Create a Patient- and Family-Centered Environment reflecting the MHS culture of caring. Increase social support. Reduce spatial disorientation. Improve patient privacy and confidentiality. Provide adequate and appropriate light exposure. Support optimal patient nutrition. Improve patient sleep and rest. Decrease exposure to harmful chemicals. 2. Improve the Quality and Safety of Healthcare Reduce hospital-acquired infections via airborne, contact and water transmissions. Reduce medication errors. Prevent patient falls. Reduce noise stress and improve speech intelligibility. 3. Enhance Care of the Whole Person by Providing Contact with Nature and Positive Distractions Decrease patient and family stress. 4. Create a Positive Work Environment Decrease back pain and work-related injuries. Reduce staff fatigue. Increase team effectiveness. Eliminate noisy and chaotic environments. 5. Design for Maximum Standardization, Future Flexibility and Growth Reduce room transfers. Facilitate care coordination and patient service. EBD features and responses as well as future study opportunities were recommended. These findings were then translated into EBD activities across the facility life cycle. Recommendations An extensive literature review has identified compelling evidence that certain EBD features and responses do in fact improve patient, staff and resource outcomes. Although almost all of the EBD research was conducted in inpatient areas, some of these features suggest application in the ambulatory care environment. Though dependent on the project concept of operations and budget, this Study supports adoption of the following

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Executive Summary

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EBD features in the program and design of virtually all new military health facilities. These features are supported by both compelling science and business case analysis. Design Single-bed Rooms with Family Zones to increase social support, improve patient privacy and confidentiality, improve patient sleep and rest, reduce hospitalacquired infections, decrease patient and family stress and eliminate noisy and chaotic environments. Provide HEPA Filtration to reduce airborne-transmitted hospital-acquired infections. Install Ceiling-Mounted Patient Lifts to reduce patient falls and decrease back pain and work-related injuries for staff. Use Sound-Absorbing Materials, Especially High-Performance SoundAbsorbing Ceiling Tiles to improve privacy and confidentiality, improve patient sleep and rest, reduce noise stress and improve speech intelligibility, and eliminate noisy and chaotic environments. Design Walled Rooms for Admitting, Examination and Treatment Spaces— rather than open-plan rooms with curtains that divide separate patient spaces—to improve patient privacy and confidentiality, provide adequate and appropriate light exposure, improve patient sleep and rest, reduce noise stress and improve speech intelligibility, decrease patient and family stress, and eliminate noisy and chaotic environments. Maximize Natural Light throughout the Building to improve patient rest and sleep, decrease patient and family stress, and reduce staff fatigue. Reduce or Eliminate Loud Noises to improve patient sleep and rest, reduce noise stress and improve speech intelligibility, and eliminate noisy and chaotic environments. Many EBD features represent good design choices and facility management practices. These often do not require significant additional front-end investments. Some additional EBD features with good supporting evidence include: - “Residential-feeling”—rather than “institutional”—waiting areas - Use of acuity-adaptable rooms for a combined intensive and intermediate care unit - Patient controls for light, glare and temperature - Improved lighting levels in medication preparation, dispensary and procedure areas - Windows in staff break rooms - Convenient food facilities for patients and families - Decentralized inpatient nursing support - Regular maintenance, cleaning and inspection of water systems - Proper water treatment practices - Avoidance of decorative water fountains in high-risk patient care areas - Frequent cleaning of high-contact surfaces - Providing sinks and hand-washing dispensers - Ensuring that HVAC systems are well maintained and operated - Use of materials and furnishings that do not emit toxins - Isolation of construction and renovation areas from patient-care areas - Providing secure access to nature - Providing positive distractions (music, appropriate art, etc.) - Providing multiple spiritual spaces and haven areas

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Executive Summary

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-

Use of softer floor materials like carpet and rubber as appropriate Ergonomic evaluation of work areas Decentralized staff support spaces (e.g., supplies and charting areas) Providing flexible spaces for interactive team work Optimizing unit adjacencies with Care Centers (e.g., Cancer, Musculoskeletal Care)

Facility Life Cycle Management and Performance (FLCMP) Model Application EBD activities were identified for every phase of the FLCMP model from strategic planning to facility sustainment—not just design, as is often thought. An EBD activity checklist for each FLCMP phase is provided in Section IV of this report. Recommended Next Steps. Much work is needed to institutionalize EBD research and findings, including the following recommended activities: - Engage senior leaders. - Partner with clinical and administrative peers. - Include patients and their families in health facility planning activities. - Review and update facility policy to include EBD-recommended features and responses. - Develop processes to harvest emerging EBD findings. - Review and restructure health facility organizations as appropriate to monitor and integrate EBD findings. - Conduct EBD research in the ambulatory and dental environments. - Disseminate EBD information. - Evaluate and refine EBD cost-estimating guidance. - Perform return on investment analyses. - Review EBD-associated outcome metric definitions and methodology. - Become a Pebble Project. - Refine the post-occupancy evaluation process. - Refine the life-cycle cost analysis process. - Publish MHS EBD experiences and lessons-learned. - Formalize current EBD working groups. Conclusion With a six-billion-dollar portfolio of new healthcare facilities and projects planned over the next five years, the MHS finds itself with a once-in-a-lifetime opportunity to both transform the healthcare infrastructure to improve patient, staff and resource outcomes and to contribute to the body of EBD science. This report provides a snapshot of the current EBD evidence applied to MHS EBD goals and principles that can be used to transform and educate the MHS healthcare community. Although the current AIA and DoD planning criteria embrace many of the recommended EBD features, the reader is encouraged to stay abreast of the latest EBD information through the Center for Health Design and is reminded that maximizing EBD investments depends on transformational leadership and clinical and business process reengineering. Employing recommended EBD features and responses across the Facility Life Cycle provides a singular opportunity to create the next generation of MHS healthcare facilities that can support the outcomes our warriors and their families deserve.

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Introduction & Overview

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I.

Introduction

The premise of evidence-based design (EBD) is that elements of a healthcare facility design have been scientifically evaluated and shown to make a positive difference in patient, staff, and resource outcomes. Some of the outcomes improved by EBD features include: improved patient and staff satisfaction, reduced hospital-acquired infections, improved patient sleep, and numerous others that will be discussed in this report. The Program and Planning Division (PPD) of the Health Facility Planning Agency of the US Army (HFPA), funded by the TRICARE Management Activity Portfolio Planning and Management Directorate (TMA PPMD), contracted Noblis, Inc. (formerly known as Mitretek Systems, Inc.) to complete research on Evidence-Based Design as a part of a Special Studies task orderi. The intent of this study is primarily educational, with a charge to educate HFPA and TMA planners about what EBD is, to examine the evidence, to understand how environment-friendly design fits in, and to determine how EBD might be applied in the military health system (MHS). Scope of Work Requirements There is a dizzying array of information available on the topic of EBD, and many groups within the MHS are addressing the issue. Noblis has attempted to interface with these disparate groups to align each group’s separate objectives and to ensure that no one is duplicating efforts. This scope of work is focused primarily on educating the HFPA and TMA facility community stakeholders. The scope required that Noblis would: Perform a review of existing literature. Talk to those who have incorporated EBD principles and features in their designs. Identify resources that might be examples of “best practices”. Deliver a written final report documenting the issues, findings, implications and recommendations related to EBD for future military medical construction projects. Conduct an education session for HFPA planners. An educational presentation (entitled “EBD: A Primer”) was presented to the Team Army audience on March 7, 2007. An expanded set of presentations was given to an audience of 70 stakeholders on June 8, 2007. These morning presentations set the stage for an interior design visioning session for the new Community Hospital at Fort Belvoir later that afternoon. This report has been through a formal staffing process to elicit feedback from the facilities planning and programming communities. Their comments have been incorporated into this final draft. With the final publication of this report, Noblis has completed all of the scope requirements for this task.

i

Contract number W91278-05-D-0039, Task Order 0014; period of performance is OCT06 through SEP07.

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Methodology The Noblis team has conducted extensive literature review, attended numerous educational meetings and conferences, applied EBD principles to the facility life cycle as it is understood in the military health system, and investigated ways of incorporating EBD principles into the MHS. To educate the team members, Noblis (with HFPA and TMA) representatives attended: Turner Healthcare’s October 11, 2006 Executive Program: "The Business Case for Better Buildings" presented by the Center for Health Design, and “The Digital, Integrated Healthcare Enterprise" presented by Siemens One. The Center for Health Design’s Health Care Design ’06 conference, November 4-7, 2006, in Chicago, IL. The Institute for Healthcare Improvement’s 18th National Forum on Quality Improvement in Healthcare, December 10-13, 2006, in Orlando, FL. The ASHE/AIA (American Society for Healthcare Engineering; part of the American Hospital Association and American Institute of Architects) 2007 International Conference and Exhibition on Health Facility Planning, Design and Construction, February 25-28, 2007, in San Antonio, TX. In the course of these sessions, members of the team spoke to many practitioners and students of EBD. The team gleaned much from their recommendations and referrals. Additionally, in the course of two conferences, the team had opportunities to tour regional health facilities that have adopted EBD principles in their new construction projects. (See Attachment 1 for details.) The Noblis team is also involved in the Epidaurus Project in the National Capital Area in the designs of Walter Reed National Military Medical Center and the New Community Hospital at Fort Belvoir. There has been a great deal of cross-pollination between Epidaurus and this study, as you will see in Section III of this report. This project is transforming the way the MHS looks at design of healthcare facilities. (For further information on this case study, see Attachment 2). Team The COTR project coordinator for HFPA is Ms. Miffy Morgan, Healthcare Planner. Additional oversight and direction is provided by LTC Mia Brennan, HFPA PPD, and by Mr. Clay Boenecke at TMA. The Noblis team consists of Eileen Malone, principal researcher and author; Julie Mann-Dooks, assistant researcher and author; Joe Strauss, architect and contributing author; and Doug Wilson, engagement director. Additional assistance was provided by Jeffrey Michaels, Noblis librarian, and Judi Potter, who helped to find multiple source articles and research studies. Overview of Report This report is divided into 5 major sections (preceded by an Executive Summary), which are detailed below.

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I. Introduction. Includes background for the study, scope of work requirements, methodology, and a description of the team. II. A Brief EBD History and Overview. A definition, brief history and overview of the science of EBD to include who the thought leaders have been and what institutions have adopted EBD features and responses. III. Current Compelling EBD Science. An overview of the compelling EBD science—organized according to the MHS EBD principles and goals—with a description of the literature review, recommended EBD features and suggested future studies. IV. EBD Activity Checklists. EBD activity checklists are provided for each phase of the Facility Life Cycle Management and Performance Model. V. Summary Recommendations, Conclusion and Next Steps. A summary of recommendations, conclusions and recommended next steps. Additionally, there are four attachments which give further information about case studies, provide the full text of Dr. Winkenwerder’s recent memo, and list the opportunities for future study that are identified in Section III.

II.

A Brief History and Overview of EBD

Our Definition of Evidence-Based Design
Science has shown that certain aspects of hospital design can improve or worsen a patient’s condition. EBD for healthcare settings uses a set of design principles that have been scientifically evaluated and shown to make a positive difference for patient, staff and resource outcomes. Specifically, EBD can make a positive difference in: Clinical and therapeutic outcomes for patients, Staff satisfaction and retention (through stress reduction and increased efficiency), Inviting familial support for the patient, and Improving resource utilization. EBD is a way of redirecting goals and reducing the risk of innovation. It has the potential to create a “community of practice” – i.e., a multidisciplinary group consisting of clinicians, administrators, patients and family members, facility and technology experts along with policy makers to solve healthcare challenges by employing scientifically derived facility, technology and clinical and business process solutions. EBD uses the scientific method—presents a hypothesis, tests it in various ways, reports the results—to rigorously study the ways in which individual elements of the built environment affect patients, their families, the facility staff, and resource utilization in healthcare delivery.

The Theoretical Lineage of Evidence-Based Design
What does “evidence-based” mean?
Evidence-Based Design in healthcare is an extension of the theories of evidence-based practice and evidence-based medicine. Evidence-based medicine stems from Professor Archie L. Cochrane’s premise that much “evidence” for best practices for medical

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treatments and interventions is available in the form of relevant randomized controlled trials. He strongly advocated that this evidence should be collected, analyzed, validated and then widely disseminated. Evidence-based medicine strives to use research-based knowledge to apply the best interventions to the clinical encounter. Evidence-based Medicine has led to Evidencebased Practice, in which clinicians, nurses and others apply research results to their subspecialty clinical practices. This same kind of scientific rigor can be applied to design elements. Kirk Hamilton (in his 2003 article "The Four Levels of Evidence-Based Design Practice“) tells us that: “Evidence-based healthcare designs are used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance, and restorative for workers under stress.”5 He goes on to say that designers and clients must collaborate to sift through the available research and the project evaluations that have been completed, and use critical thinking skills to develop appropriate solutions to each client’s unique design or healthcare delivery problems. EBD is neither a recipe nor a “cookie-cutter” approach; a lot of latitude is maintained for the design team’s creativity and innovation. Usually, an evidence-based healthcare design will result in demonstrated improvements in the organization’s clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures. But, as Hamilton warns, the EBD label should be applied only to projects in which current research has impacted the design and the hypothesized outcomes can be sufficiently measured1 — those projects that are truly “evidence-based”. For eons, good healthcare facility design has incorporated positive healing features. In Ancient Epidaurus, 6th century BC, patient rooms in the temple to Asklepious were oriented to the sun, based on a belief that the power of the sun was healing. We now have scientific proof that morning sunlight does in fact help heal. Evidence-Based Design attempts to make empiric what was once intuitive.

The Healing Environment
The ultimate goal of EBD is the creation of a healing environment. EBD is only one of three essential ingredients needed to produce this healing space or environment.

Transformational Leadership & Culture

Healing Environment
EvidenceBased Design Re-engineered Clinical & Administrative Processes

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As depicted in the model above, EBD cannot occur in a vacuum; it must be accompanied by both process re-engineering and cultural change. This message is strongly reiterated by those who have applied EBD features to their building projects. Leadership must make a commitment to the principles behind creation of a healing environment and ensure that these principles are incorporated into their entire organizational culture, from the clinicians to the nurses to the housekeeping staff to the administrators. Without cultural and process change, the most “advanced” EBD healthcare facility is still only a building that houses healthcare-related activities. In the modern age, healthcare is highly dependent – for diagnosis and for treatment – on the technologies that have been created to help people live longer. But the scientific approach to healthcare often leaves out the “care” portion; diseases are isolated and treated without paying attention to the fact that a patient is more than a sum of his or her ailments. The counterpoint to this view is patient-centered care.

Patient- and Family-Centered Care
Patient- and Family-Centered Care is an innovative approach to the planning, delivery and evaluation of healthcare that is based on mutually beneficial partnerships among healthcare providers, patients and families.ii Core concepts include: Dignity and respect Information sharing Participation Collaboration It would be nice to think that all clinics and hospitals practice patient-centered care, but sadly, many do not embrace a patient-centered culture. Many clinicians believe that they know what is best for the patient, so don’t ask the patient how they would like their own treatment to proceed. There is substantial evidence that involving the patient in his/her own destiny and decision-making reduces anxiety and helps speed the healing process. EBD recognizes the effect of the built environment on healing and, as such, strongly supports a patient-centered care philosophy.

Quality
Another factor fueling EBD inquiry is the recognition that the US healthcare system is failing to meet quality standards, that our system does not consistently “translate knowledge into practice and apply new technology safely and appropriately”2; and the recognition that the built environment has an effect on patients and their families, on staff, and on various outcomes. The Institute of Medicine (IOM) established a quality initiative in the late 1990s and subsequently published two seminal reports: To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001). These reports call for a system-wide reform of healthcare in the US.
ii

Family refers to two or more persons who are related in any way – biologically, legally or emotionally. Patient and families define who is in their family.

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Attendance at the 18th National Forum on Quality Improvement in Healthcare3 in December 2006 revealed a plethora of stunning statistics about how dangerous our hospitals really are: Of the 37 million discharges last year, between 3% and 17% of the patients were injured. Chance of dying through error is somewhere between 1 in 300 and 1 in 700. Chance of experiencing an adverse event is 1 in 30. 10% of all patients get the wrong medication. For every 1,000 patient days, 3.5 patients fall; and the unlitigated cases cost $10K each. Last year, 90,000 patients died of hospital-acquired infections. Only 14-30% of staff comply with hand-washing standards. If we know there are certain design elements that contribute to a more efficient and effective healing environment, shouldn’t we be building these into every new or renovated healthcare facility? We must, at least, ensure that we are not “hard-wiring” error into our built environment.

The Evolution of Evidence-Based Design
EBD Research, Advocates and Researchers – A Timeline
Professor Cochrane’s premise for evidence-based research and practice was published in the early 1970s. Subsequently, the explicit methodologies used to determine "best evidence" were largely established by the McMaster University research group led by Professors David Sackett and Gordon Guyatt. Professors Sackett and Ian Chalmers are often cited as leaders of the Evidence-based Medicine movement. In the early 1970s, studies were being done on “behavioral architecture”, in which the effect of the environment on its human inhabitants -- or how the design of a built environment affects human behavior -- is studied. In 1978, Angelica Thieriot envisioned a new kind of hospital, one that put the patient front and center, personalizing the experience and promoting healing. She formed a planning and advisory board which became Planetree, established as a non-profit organization with an emphasis on facilitating patient-focused care. Planetree recognizes the importance of the built environment and the role that it plays in patient’s healing. In the 1980s, Roger Ulrich did a pioneering study that showed that surgical patients with views of nature had improved clinical outcomes (i.e., fewer complications, less pain, reduced lengths of stay) over those who had a view of a brick wall. In 1985, the first Planetree medical/surgical unit was opened in California. The Planetree organization pioneers patient-centered care methods, and as such, tracks and disseminates information based on the same research that is discussed here.

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Gordon Guyatt coined the term “evidence-based medicine” (EBM) in a published paper in 1992. In 1993, the Center for Health Design (CHD) was founded by a group of healthcare and design professionals. Their entire mission is to transform healthcare settings into healing environments that improve outcomes through the creative use of EBD. They have become the preeminent collector of all kinds of research and information on EBD, from the fields of evolutionary biology, neuroscience, environmental psychology, and psychoneuro-immunology (which is the effect of emotions on the immune system and psyche). Their vision is for healthcare design to contribute to health, rather than adding to stress. Shortly thereafter (in 1994), the Cochrane Collaboration was formed. This is a webbased meeting place for clinical review and central data repository that hosts the Cochrane Library, which contains information about more than 3,000 reviewed, randomized clinical trials from all over the world. (See www.cochrane.org .) The Collaboration employs a systematic review process to validate clinical trials. In 1997, the Center for Health Design published a report that compiled all available knowledge on the topic. At the time, the Johns Hopkins research team found that there were only 84 significant research studies. Roger Ulrich categorized the extant research into 5 areas: Access to nature, control, positive distractions, social support, and environmental stressors. The Center recognized a need to fill in many of the gaps, and began a comprehensive research agenda. In 1998, CHD partnered with the Picker Institute to study consumer preferences in healthcare settings. The results: consumers want a connection with staff; a place that fosters well-being, is convenient, accessible, confidential, private, demonstrates care for their families, is considerate of their current state, and is close to nature. When the Institute of Medicine (IOM) reported on improving the quality of care delivery (in the reports To Err Is Human in 1999 and The Quality Chasm in 2001), they identified six factors for best practices. These are patient-centered, timely, efficient (reduces waste), equitable (accessible to all), effective delivery of care, safe. All of these are EBD principles. The Center for Health Design initiated its Pebble Projects in 2000 to establish a group of peers measuring and sharing their specific outcomes regarding EBD applied to any renovation or new building project. Over 40 organizations have participated to-date. The hope is that the Pebble Projects will create a ripple in the healthcare industry and spur more rapid advancement of EBD principles. Roger Ulrich and Craig Zimring performed another meta-analysis of the data in 2004, and they found 600 studies available. Their meta-analysis also included the establishment of a 5-star rating system to classify which studies and results are most compelling and most strongly evidence-based, which have been updated and included in this report.

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EBD Timeline
Archie Cochrane: “evidence-based” research methods Planetree established
(1978)

Cochrane Collaboration formed First Planetree M/S unit opens
1985 1990 1995

1999: IOM publishes To Err is Human
2000 2003

2001: IOM publishes The Quality Chasm

2006 DoD Facility Planning Criteria & AIA Guidelines both recommend single-patient Inpatient rooms

1970

1980

2005

2007

Behavioral Architecture studies

1980s: Roger Ulrich’s pioneering studies on healing environments

CHD’s analytical summary reports

Ulrich & Zimring Meta-Analyses

The Center for Health Design (CHD) established

2003 JCAHO begins revision of Infection control standards

Pebble Project Initiated

Numerous professional associations (American Institute of Architects–AIA, Joint Commission on the Accreditation of Healthcare Organizations–JCAHO, Center for Healthcare Effectiveness Research, American Society for Healthcare Engineering–ASHE, and the Institute for Healthcare Improvement–IHI) take an active interest in EBD principles, and many have begun to include EBD recommendations in their professional standards and guidelines. The DoD Space Planning Criteria, for example, have recently changed to recommend single-bed inpatient rooms. In 2003, JCAHO began a process to revise their infection control standards. Joint Commission Resources published Infection Control Issues in the Environment of Care in 2005 as a resource for healthcare organizations to help their environment of care professionals to prevent as many hospital-acquired infections as possible. They advocate a multi-faceted approach, which recognizes the interdependence of processes, leadership, and the healthcare environment. JCAHO references AIA, ASHE and Center for Disease Control guidelines for controlling infection during construction. All agree on the need for a pre-construction infection control risk assessment. The 2006 Guidelines for Design and Construction of Health Care Facilities4, published by the American Institute of Architects and the Facility Guidelines Institute, suggests, but does not mandateiii, many features that have been studied in the EBD arena and proven to have a positive impact on patients, staff or facility/institutional resources. They, too, advise the early assembly of an interdisciplinary design team. Most of the major EBD
iii

In their Appendix material, which is intended to be “educational or explanatory” in nature.

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features that will be discussed later in this report are included in the new AIA Guidelines. EBD-supported standards that maybe be considered for the 2010 Guidelines edition include patient lifts, acoustic standards to ensure privacy and confidentiality, standards for surfaces and finishes to support infection control, and placement of hand-washing facilities. The 2006 Guidelines states “Sustainable design, construction and maintenance practices to improve building performance shall be considered in the design and renovation of health care facilities”. The sustainable design components include site selection and development, waste minimization, water quality and conservation, energy conservation, indoor air quality, and environmental impact of building materials. The Guidelines references the Green Guide for Health Care and the US Green Building Council’s LEED Green Building Rating System. The results of the Pebble Project studies are being incorporated into the data repository held by the Center for Health Design, and will be used in the Robert Wood Johnson Foundation-sponsored update from CHD expected in the summer of 2007.

EBD Resources
Almost all EBD research has occurred in the private sector, with the vast majority of the work focused on the inpatient setting. Many organizations have been studying EBD for 10 years or more. A summary of the more seasoned EBD experts is provided below: Multiple academic centers exist to study evidence-based design and to further the research into this discipline. The Georgia Institute of Technology and Texas A&M University are widely regarded as the definitive authorities. Georgia IT is engaged in extensive research and meta-analysis of EBD hypotheses. Craig Zimring is on their faculty. Texas A&M has a Center for Health Systems & Design, sponsored by the Colleges of Architecture and Medicine. Both Kirk Hamilton and Roger Ulrich are on the faculty there. For a comprehensive compilation of EBD articles and research, see the Center for Health Design website (www.healthdesign.org). It contains rich details of both past and on-going Pebble Project research. CHER (the Coalition for Health Environments Research) recently became a part of the Center for Health Design. Their information is also available on the CHD website. (http://www.healthdesign.org/CHER/). The Robert Wood Johnson Foundation provides research grants in healthcare, in four particular areas of focus (including improving the quality of care). Like the Center for Health Design, RWJF publishes the results of their research. A link is available to RWJF from the Center’s website.

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Healthcare Without Harm is an organization that promotes a safe healthcare environment, and encourages responsible use of materials. They have done a lot of research on toxins in building materials, and advocate toxin-free built environments. Their website is www.noharm.org/us/. The Green Guide for Health Care recommends guidelines for construction materials and furnishings with the objective of minimizing indoor air contaminants that are odorous, potentially irritating and/or harmful to the comfort and well-being of both installers and occupants. The Green Guide for Health Care is available for download from their website: www.gghc.org.

EBD Practitioners: Health Care Facilities
While many individual healthcare facilities have recognized the importance of EBD and tried to incorporate EBD principles into the designs of their new facilities, there are also two large groups of facilities that have adopted EBD: the Planetree affiliates and the hospitals associated with CHD’s Pebble Project. Planetree Affiliates, of course, use the Planetree principles of patient-focused care. Their website states: “A growing body of scientific data points to improved patient outcomes and satisfaction as a result of design factors which are home-like, barrier free, support patient dignity and encourage family participation in care. Facility designs utilizing Planetree's principles result in life-enhancing, healing environments.”5 There are now over 55 affiliated hospitals in 32 states, Canada and Europe. These are listed on their website (www.planetree.org), and include individual website addresses for reference. The Center for Health Design’s Pebble Project has attempted to chronicle and codify the EBD innovation process. Pebble Projects were initiated by the Center for Health Design to establish a group of peers measuring and sharing their specific outcomes regarding EBD applied to any renovation or new building project. Over 40 organizations have participated to-date, and though each organization determines its own research agenda, there is a standardized research model and matrix for data collection. Pebble Project participants are required to analyze their goals, develop hypotheses, search the literature, translate their findings into new and innovative solutions, and measure their results upon occupancy. Additionally, they must share their findings with the healthcare industry at large (through publication in a peer-reviewed journal). In addition to these rich resources, Noblis has compiled a list of facilities that are repeatedly referred to as leaders in EBD innovation. A few hospitals have even attempted to incorporate EBD features and responses into facility renovations and reconfigurations. The table that follows attempts to focus the reader on the EBD attributes that have been incorporated by each facility.

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Hospitals Doernbecher Children’s Hospital Portland, OR Woodwinds Health Center Woodbury, MN Genesys Health System Grand Blanc, MI
6

EBD Features Incorporated Family-Centered Care environment; Cancer Center for Children Patient- & Family-Centered Care; private patient rooms, family accommodations; holistic and alternative care Patient-focused philosophy; the hospital learned from early Operations mistakes http://www.planetree.org/about/welcome.htm Patient-focused care innovations: single-patient rooms, inclusion of family, access to nature, natural light, stress-reducing elements like music, art, etc. First hospital-wide Planetree affiliate http://www.healthdesign.org/research/pebble/ Infection control (single-patient rooms); relationship between patient acuity, time standards and productivity of nursing staff; Acuity-adaptable patient rooms, decentralized nursing stations, dedicated spaces for family. Acuity-adaptable, private patient rooms with patient, family & staff zones; access to natural light; barrier-free nursing stations; noise-reducing features; peaceful settings Infection control (HEPA in whole ED); [has also researched surge capacity issues] Ambulatory Practice of the Future (not yet built) Patient & Staff Safety focus; completely standardized rooms; integration of technology Ambulatory Care – how attractiveness of waiting rooms affects perceived wait times and staff interaction quality

Planetree Affiliates

Mid-Columbia Medical Center The Dalles, OR Pebble Project Hospitals 7 Bronson Methodist Kalamazoo MI Clarian Hospitals Indianapolis, IN Dublin Methodist Hospital Dublin, OH

ER One – Washington Hospital Center Washington, DC Massachusetts General Hospital Boston, MA St. Joseph’s Community Hospital West Bend, IN Weil Cornell Medical Center College New York, NY

MHS facility planners may want to visit some of these “early adopters” in order to see certain features “in action” and to discuss the realized outcomes and challenges before including particular EBD features or responses in MHS projects.

EBD in the Military Health System
Much attention has been paid to EBD in the military health system in recent years. The following groups and initiatives have served to focus MHS leadership on issues that are related to improving medical outcomes and patient satisfaction as well as on implementing major capital planning investments within the system.

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Epidaurus Project and EBD Working Group The Epidaurus Project was born in 2001, led by CAPT Fred Foote, who engaged the academic community to identify the attributes of the hospital of the future that was patient- and family-focused. The MHS Office of Transformation has established a triservice, interdisciplinary EBD team with expertise in these subject areas. There is an OSD-HA EBD Group, consisting of clinicians, facility planners, and architects, whose mission is to promote, codify and institutionalize patient-centered and evidence-based design throughout the MHS capital facility landscape. The Epidaurus Project and the EBD Working Group together have identified MHS EBD principles and goals to guide the design and construction of the new hospitals in the National Capital Area (NCA) and other projects and to establish mechanisms to review EBD features and responses across the facility life cycle. EBD as it relates to DoD Space Planning Criteria When revised in 2006, the updated DoD Space Planning Criteria embraced many AIA 2006 recommendations, the highlights of which include: single-bed rooms, acuityadaptable rooms, decentralized staff support on inpatient units, and eliminating the use of curtained cubicles in the Emergency Department (i.e., replacing curtains with walls). QDR 8 Every four years, the Department of Defense is required to conduct a review of its operations and to articulate long-range (20-year) planning for the entire organization. In 2006, the MHS response to the Quadrennial Defense Review was the April 3rd Roadmap for Medical Transformation, which identified two initiatives relevant to this study: #8: Transform the Infrastructure and #17: Effective Patient Partnerships to Sustain the Benefit. Among other issues, QDR8 says that MHS will “revise existing space and construction criteria to reflect use of accepted industry best practices” and also refers to the need for all BRAC projects to be complete by 15 SEP 2011. The objective of QDR17 is “to improve patient care, enhance patient satisfaction, and reduce the cost of healthcare by leveraging patient partnerships to achieve evidence-based healthcare outcomes”.8 The Office of Transformation has established an interdisciplinary team to ensure that military treatment facilities (MTFs) comply with QDR17 recommendations. Several current Special Studies by Innova, VWI, and executive-level support by Martin, Blanck & Associates are sponsored by the Office of the Secretary of Defense for Health Affairs (which oversees TMA). OSD-HA Secretary’s Memo The Assistant Secretary of Defense (Health Affairs), Dr. Winkenwerder, signed a memo on 22JAN07 requesting that patient-centered and evidence-based design principles be applied across MILCON construction projects. It said: “I request that you … apply patient centered and evidence based design principles across all medical MILCON construction projects. A growing
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body of research has demonstrated that the built environment can positively influence health outcomes, patient safety, and long-term operating efficiencies …” This memo (the full text of which is Attachment 3) recognizes, at the top levels of the MHS, the merit in evidence-based design and a patient-centered approach to healthcare. NCA Design When the BRAC decisions were announced on 13 May 2005, planning and programming teams began work in the National Capital Area (NCA) to create the Walter Reed National Military Medical Center at Bethesda and the new Community Hospital at Fort Belvoir as the two inpatient facilities of an integrated healthcare delivery system. The NCA projects have served as an EBD “living laboratory” for those EBD features and responses with both compelling science and a strong business case. Many EBD features and responses were included in the planning and programs for design for both projects, which are described more fully in Section III of this report. In January 2007, the Epidaurus Project and EBD Working Group began focusing their efforts on the design for both projects to ensure that the key EBD features were included. Communities of practice were engaged for those desired EBD features and responses not a part of DoD criteria, such as HEPA filtration and ceiling-mounted lifts. This work continues as a means to mitigate the risks associated with these innovations and to conduct return on investment analysis. This “living laboratory” experience obviously has broad implications for the MHS as a whole, and a sense of urgency has developed around sharing this report as a first step to inform the facilities community and as a means to further EBD application in other MHS projects by harvesting the current EBD science and NCA experience.

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III.

Current Compelling EBD Science

The purpose of this section is to provide the reader with an overview of the EBD literature, recommend EBD features and responses, and suggest future MHS studies. This section is organized to correspond to the EBD Principles and Goals identified by the MHS in order to facilitate a practical application of the findings in this report. A limitation of this report is that almost all of the EBD research has been conducted in the inpatient environment, with little specific research in the ambulatory care setting or dental community, two healthcare settings of great interest to the MHS. However, many of the Recommended EBD Features and Responses would seem to have generalized applicability in any setting—a premise that should be tested. Literature Review and Key Information Sources Thousands of EBD articles exist. In the past three years, a number of comprehensive evidence-based design reviews of the literature have been conducted with great success. The key articles that were associated with improved patient, staff and resource outcomes (as identified in those comprehensive reviews) were further scrutinized for this report. More recent EBD articles were also used. Comprehensive Reviews of the EBD Literature 2004 - “The Role of the Physical Environment in the Hospital of the 21st Century” The first comprehensive review, published in 2004, was funded by The Robert Wood Johnson Foundation and was conducted by Dr. Roger Ulrich from Texas A& M University and his team, in partnership with The Center for Health Design. They reviewed more than 600 studies, finding rigorous research that linked the physical environment to patient and staff outcomes.9 The Center for Health Design then translated the literature review into a scorecard that ranked the strength of the literature using a star system, with 5 stars meaning a great deal of research has been conducted and one star ( ) indicating little research conducted. These scorecards are divided into four categories: Patient stress, staff stress, patient safety, and quality, and are shown below.10 Patient Stress Scorecard
Reduce stress, improve quality of life and healing for patients and families
Reduce noise stress Reduce spatial disorientation Improve sleep Increase social support Reduce depression Improve circadian rhythms Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients and families Provide positive distraction Patient stress (emotional duress, anxiety, depression)

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Staff Stress Scorecard
Reduce staff stress/fatigue, increase effectiveness in delivering care
Reduce noise stress Improve medication processing and delivery times Improve workplace, job satisfaction Reduce turnover Reduce fatigue Work effectiveness; patient care time per shift Improve satisfaction

Patient Safety Scorecard
Improve patient safety and quality of care
Reduce nosocomial infection (airborne) Reduce nosocomial infection (contact) Reduce medication errors Reduce patient falls Improve quality of communication (patient – staff) Improve quality of communication (staff – staff) Improve quality of communication (staff – patient) Improve quality of communication (patient – family) Increase hand washing compliance by staff Improve confidentiality of patient information

Quality Scorecard
Improve overall healthcare quality and reduce cost
Reduce length of patient stay Reduce drugs (see patient safety) Patient room transfers: number and cost Re-hospitalization or readmission rates Staff work effectiveness; patient care time per shift Patient satisfaction with quality of care Patient satisfaction with staff quality

The score cards provide an important visual tool that summarizes the EBD science strength relative to resolving key issues. Work is underway at the Center for Health Design to view this body of science through another lens, by asking, “What are the top ten EBD features and responses?”11 Another key question for future consideration might be, “If you only had limited funds, which EBD investments will give you the greatest return?”

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2005 – “The Hospital Built Environment: What Role Might Funders of Health Services Research Play?” The Agency for Healthcare Research and Quality contracted with the Lewin Group, Inc., to address the relationships between the hospital design and construction and the factors that influence patient and staff safety and outcomes. Their findings are consistent with those of Ulrich.12 2006 – Improving Healthcare with Better Building Design The Center for Health Design, with Sara O. Marberry as editor, published this EBD primer book as a part of the American College of Healthcare Executives Management Series. Ulrich and his original team, along with some new contributors from the interior design, environment and business communities provided this comprehensive resource on the subject by updating and validating many of the findings discussed in the 2004 literature review cited above.13 2006 – “Designing for Quality: Potential for Facility Design to Elevate Patient Outcomes” The Healthcare Advisory Board published a Business Brief from their Innovations Center, in which they provide a framework for identifying those features that have a positive impact on both financial performance and clinical outcomes, and recommend the following as “A Good Bet”: - Private rooms - Standardized room design - Efficient unit layout - Ceiling lifts - Natural lighting14 2006 -2007 – The Center for Health Design Research Papers Dr. Anjali Joseph, Director of Research, and members of her team at The Center for Health Design have produced several EBD subject-focused review articles on noise, infection, light and the workplace, which update Ulrich’s findings for each topic. These are: “Sound Control for Improved Outcomes in Healthcare Settings” 15 - January 2007 “The Impact of the Environment on Infections in Healthcare Facilities” 16 - July 2006 “Impacts of Light on Outcomes in Healthcare Settings” 17 - August 2006 “The Role of the Physical and Social Environment in Promoting Health, Safety and Effectiveness in the Healthcare Workplace” 18- November 2006 2007 – Anticipated Reviews The Robert Wood Johnson Foundation recently funded Dr. Zimring and the Center for Health Design to complete a second comprehensive meta-analysis article, which will incorporate many of Dr. Joseph’s findings in the articles cited above and will be published in the summer of 2007.19 Other Key Information Resources Building environmentally responsible hospitals represents another EBD facet. This goal is translated into sustainable design principles that result in healthier healthcare

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buildings.20 The Green Guide for Health Care is a metric tool for evaluating health and sustainability of building design, construction, maintenance and operations for the healthcare industry. The self-certifying system is modeled after the U. S. Green Building Council’s (USGBC) LEED rating system.21 Recommended EBD Features and Responses For each goal, recommendations are made with regard to the EBD features and responses that would best support achievement of the desired outcomes. EBD features include actual elements of the built environment, while EBD responses include other facility life cycle management and performance activities that augment EBD practice or building material choices. Design always requires choices mitigated by many circumstances, not the least of which is the budget. However, many EBD features can be achieved through good design and do not require an additional front-end investment; these are also included for consideration. Some of the recommended EBD features are not currently supported by DoD criteria. Each one deserves further scrutiny and perhaps a return on investment (ROI) analysis. A simple scheme is provided to qualify the recommendations: An asterisk (*) at left indicates those EBD features supported by both compelling science and a strong business case. Future Study Opportunities At the conclusion of each goal discussion, potential MHS study opportunities are identified, including many with a unique military focus. These are gathered in a quickreference list as Attachment 4.

EBD Principle 1: Create a Patient- & Family-Centered Environment
Patient and family-centered care serves as the philosophic focus for EBD, reflecting an MHS culture of caring. The MHS has identified a number of EBD goals to achieve this principle: increase social support, reduce spatial disorientation, improve patient privacy and confidentiality, provide adequate and appropriate light exposure, support optimal patient nutrition, improve patient sleep and rest, and decrease exposure to harmful chemicals. Expected patient, staff and resource outcomes associated with achieving the seven goals associated with creating a patient- and family-centered environment include: Improved patient and family satisfaction with support provided to encourage family engagement and fewer patient falls and medication errors, with their associated costs. Improved patient satisfaction with wayfinding and decreased staff time providing directions. Improved patient satisfaction with privacy and confidentiality. Improved patient satisfaction, decreased pain and/or pain medication use and decreased length of stay, as a result of adequate light exposure. Decreased healthcare costs.

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Improved patient satisfaction and, potentially, patient length of stay by optimizing patient nutrition with family support. Improved patient satisfaction with potential shorter lengths of patient stays with improved patient rest and sleep. Improved patient satisfaction by providing adequate parking convenient to building entrances and patient services.

Goal 1-1: Increase Social Support
Literature Review
Many studies have demonstrated that increased social support reduces patient stress and can improve specific physiologic responses and ultimately, patient outcomes. In this vein, “social support includes emotional support or caring derived through interpersonal relationships and tangible assistance from others.”22 For example, Uchino and Garvey, (1997) found that subject systolic and diastolic blood pressure was reduced when social support was available during acute psychologically stressful situations.23 Although more research remains necessary to understanding the ability of the built environment to increase or hinder social support, several EBD studies have demonstrated—primarily in the behavioral health and nursing home environments—that increased social interaction can change patient outcomes. Holahan (1972) found that side-by-side seating along room walls inhibits social interaction with hospitalized male psychiatric patients, while those seated at small tables demonstrated more personal interaction.24 Another study found that geriatric patients with senile dementia consumed more food and were more communicative when meals were consumed at small rather than large dining tables with movable chairs.25 Ulrich et al (2006) found a great deal of evidence that single-bed rooms best supported the presence of family and friends primarily because most include additional furniture for guests.26 A study by Sallstrom, Sandman and Norberg (1987) found that open bay, multi-bed rooms on a geriatric unit (for patients mostly with neurological diagnoses) actually deter family presence, with about 59% of the relatives describing the atmosphere as frightening and aggressive.27 Intensive care units historically have the most restrictive visiting hours. A new neuroscience intensive care unit at Emory University Hospital has recently adopted an open visiting hours policy after moving into a newly constructed unit in which patient rooms include a family-zoned living area with a chair that folds into a bed.28 Preliminary results show improved patient and family member satisfaction and acceptance by nurses. The Society of Critical Care Medicine has recommended that ICUs offer open visiting hours and increase family involvement.29

Recommended EBD Features or Responses
* Single-bed Patient Rooms Both the American Institute of Architects Guidelines (2006) and DoD Space Planning Criteria (2006) recommend that most, if not all rooms on a unit be single-bed. DoD Space Planning Criteria for a single-patient room includes space for a sleeper chair and a side chair, which can be used by family members and visitors.

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Waiting Rooms and Lounges. Moveable furniture in small, flexible groupings with a variety of seating to accommodate the widest range of patients is recommended—rather than the military “dress-right-dress” approach used in many MHS facilities today. The goal is to create a space that looks more like a living room than an institutional environment.

Future Study Opportunities
Active Duty Roommates The presence of a roommate has been found in multiple studies to be more stressful than restorative, primarily because of noise and loss of privacy. However, the “buddy” approach pervades military culture from training base to battlefield. Do active duty patients experience the same sort of stress when they have an active duty roommate as is seen in the civilian population experience? Behavioral Health Roommates Unlike other inpatient specialty units, behavioral health staff in the BRAC NCA projects requested semi-private rooms to further the therapeutic milieu approach. Civilian inpatient behavioral health facilities seem to be moving towards private rooms. What are the benefits and consequences for patient, staff and resources with either choice?

Goal 1-2: Reduce Spatial Disorientation
Literature Review
Navigating hospitals can be a significantly stressful experience for patients and visitors who are already stressed. Many patients must recover from the spatial disorientation associated with their arrival before they can focus on the purpose for their visit. Not only patients and visitors are affected by poor wayfinding; Zimring (1990) found that over 4500 hours of staff time in a single year was spent providing direction at one 604-bed tertiary hospital—at an estimated cost of over $200,000.30 Good wayfinding is more that just clear building signage. An integrated wayfinding system should include four components, though only the last two components are a product of design: (1) administrative and procedural information, (2) local information, (3) external building cues and (4) global structure.31 Hospital or healthcare facility external building cues to support patient entry deserve special scrutiny because they can ease the patient’s arrival and deliver a powerful first impression. It is important not to forget about entry from parking garages, which are often dark and disorienting. Malkin (2006) recommends the following space planning strategies to improve wayfinding:32 1. Use key architectural landmarks (e.g., a view of a garden, courtyard or perhaps another building on campus that has a memorable presence) to serve as a primary visual cue. 2. Maintain contact with the outdoors for all main artery corridors, if possible. 3. Use architectural features such as unique art work, atriums, and ceremonial stairs as part of the wayfinding aids. 4. Pay particular attention to building entries from parking garages.

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Signage using common language and logical room numbering is also important. Ulrich et al (2006) found more than 17 studies examining hospital wayfinding, but hospital building complexity and variation made it difficult to isolate single influences of design on wayfinding performance or patient and visitor stress.33 A recent Washington Post article described literacy problems that further complicate signage selection and provision of wayfinding information. Patient-friendly navigation signs using icons and pictures have been helpful to non-English speakers and others challenged by complex medical terminology.34

Recommended EBD Features or Responses
Simulate Wayfinding Experiences Simulate wayfinding experience options as a component of design review, beginning with the block design. Computer Aided Design (CAD) technology can facilitate testing of design and wayfinding options with patient and staff volunteers. Ensure signage is logical and well understood by a sample group of volunteers.

Future Study Opportunities
MHS Wayfinding Stress Conduct studies to ascertain the magnitude of MHS patient and visitor stress associated with poor wayfinding and consequent spatial disorientation. A first step might be a question on MHS patient satisfaction surveys about satisfaction with ease of wayfinding. A sub-component study might focus on the tertiary medical centers to which combat casualties are evacuated and to which their families arrive during a uniquely stressful time.

Goal 1-3: Improve Patient Privacy and Confidentiality
Literature Review The built environment significantly contributes to the quality of patient privacy and confidentiality. Barlas et al (2001) found that emergency department patients assigned to curtained multi-bed spaces versus rooms with solid walls reported less visual and auditory privacy – and 5% of the patients withheld portions of their medical history or refused parts of their physical examinations.35 Joseph and Ulrich (2007) provide an excellent overview of speech privacy and patient confidentiality.36 All patientidentifiable information communicated orally must be kept private according the 1996 Health Insurance Portability and Accountability Act (HIPAA). Speech privacy, indicated by a privacy index, refers to how well a private conversation can be overheard by an unintended listener. Armstrong Ceiling Systems 2003 provides a privacy index rating to quantify how well a private conversation can be overheard by an unintended listener, which is provided below along with the recommended level of privacy for different hospital spaces.37

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Privacy Level Confidential

Privacy Index Rating 95-100% of conversations partially overheard but not understood outside the space 80-95% - conversations may be heard, are only partially intelligible 60-80% - most conversations will be overheard and intelligible to unintended listeners Less than 60% - all conversations can be fully overheard and understood

Recommended Hospital Spaces Admitting areas, areas where patients discuss their personal health, psychiatric and psychological testing rooms, hematology labs, exam rooms, etc. Enclosed single-patient rooms Not desired

Normal Marginal/Poor

No Privacy

Not desired

Current AIA Guidelines recommend that public circulation and staff and patient circulation should be separate wherever possible and that private alcoves or rooms should be provided for all communication concerning personal information relative to patient illness, care plans, and insurance and financial maters. Acoustic privacy is an area of interest for the 2010 AIA guidelines and acoustic engineers are working with the guidelines committee.

Recommended EBD Features or Responses * Single-bed Rooms. Patient privacy and confidentiality is best supported in a single-bed room. * Use High Performance Sound-Absorbing Acoustical Ceiling Tiles Install high-performance sound-absorbing acoustical ceiling tiles to prevent sound from bouncing off the ceiling into adjoining spaces. Attention should be paid to surrounding structures (room and corridor walls and ductwork) as well as to tile cleanability. Avoid Open-Plan Cubicle Curtained Admitting, Examination and Treatment Spaces. Ensure that admitting, exams and treatments occur inside walled rooms. Current DoD Space Criteria includes open-plan rooms with cubicles separated by curtains: e.g., in the post-anesthesia care unit, primary care clinic treatment rooms. A ROI analysis is needed. Provide an Adequate Number of Private Consultation Rooms Ensure that there are walled rooms for providers to conduct meetings with families and in public areas like reception and waiting rooms where private information may be discussed. This is currently supported by DoD Space Criteria. Avoid Physical Proximity between Staff and Visitors Ensure that admission and reception areas are designed to avoid physical proximity between staff and visitors to minimize overhearing confidential telephone conversations and discussions.

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Future Study Opportunities
MHS Patient Satisfaction with Privacy Identify current patient satisfaction with regard to privacy and identify those physical attributes that contribute both positively and negatively. Evaluate Speech Privacy in MHS Open-Rooms with Multiple Beds or Chairs DoD Space Criteria continues to support open rooms, with multiple beds and chairs for a number of care areas, such as the post-anesthesia care unit and primary care treatment rooms. Speech privacy should be evaluated and the criteria modified, as appropriate.

Goal 1-4: Provide Adequate and Appropriate Light Exposure
Literature Review
Light impacts human health and performance. Studies have shown that daylight exposure reduces depression among patients with seasonal affective disorder and bipolar depression, improves sleep and circadian rhythms, lessens agitation among dementia patients, eases pain, decreases length of stay in hospitals and improves adjustment to night-shift work among staff.38 Multiple studies have found that morning bright-light exposure is more effective in reducing depression than evening-light exposure.39 Walach et al (2005) found that elective lumbar and cervical surgical patients cared for on the bright side of the same hospital were exposed to 46% higher-intensity sunlight, which resulted in less perceived patient stress and pain, necessitating 22% less analgesic use and 21% less medication cost.40 Other studies have shown that higher light levels are associated with better performance of complex visual tasks and that light requirements increase with age.41 One study conducted at the outpatient pharmacy of Walter Reed Army Medical Center found that pharmacy dispensing error rates for both contents and labeling were significantly less at working surfaces lit at 1,500 lux as compared with 450 lux.42

Recommended EBD Features or Responses
* Maximize Use of Natural Light throughout the Hospital Provide Large Windows in Inpatient Rooms Large windows will help to maximize exposure to natural light. Orient the Greatest Number of Inpatient Rooms to Receive Early Morning Sun Exposure Facilitate Control of Glare and Temperature Glare and increased temperature can be associated with increased exposure to daylight, necessitating a means for the patient, families and staff to control both. Provide High Lighting Levels for Complex Visual Tasks Key complex areas requiring bright light include medication preparation and procedure areas.

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Provide Windows in Staff Break Rooms Although more research is needed, it appears that maximizing access to natural light reduces staff stress and improves both circadian rhythms and staff satisfaction.

Future Study Opportunities
MHS Patient Satisfaction with Lighting Identify current patient satisfaction with regard to lighting and the ability to control associated glare and temperature.

Goal 1-5: Support Optimal Patient Nutrition
Literature Review
The classic quip is that you do not go to a hospital to get the best food. However, Planetree has long embraced the belief that nutrition plays an important role in healing and so engaging family members in the provision of patient nutrition represents an important feature of their patient-centered philosophy. Many of the Planetree facilities include full-kitchen capability for use by volunteers, families and patients as a means to improving patient nutrition and nurturing associated with food preparation and consumption. Although this goal is not classically found in the EBD literature, it represents an important goal of the Epidaurus Project. Many of our combat-wounded patients experience lengthy hospitalizations, far from home. DoD Space Planning Guidelines provide alternatives for food service delivery that include a room service approach, which allows the patient to order what they want to eat when they want to eat. On each inpatient unit, a small nutrition room with a refrigerator and microwave is provided to support this effort. Many military and civilian hospitals now house national chain restaurants and other food services to offer convenient food access and improve other revenue sources. The degree to which these services improve patient nutrition and provide family access to food is not known.

Recommended EBD Features or Responses
Provide a Design that Encourages Family Participation in Patient Nutrition Provide Convenient Food Facilities

Future Study Opportunities
Assess Current MHS Food Service Facilities and Family Involvement with Nutrition A nutrition support question might be included on the MHS patient satisfaction survey as a first step to understanding the current status of this issue. Simultaneously, a community of practice involving patients, their family members, nutritionists, nursing staff and providers could be formed to: Explore the degree to which a problem exists, particularly for war-wounded patients who experience lengthy hospitalizations far from home. Identify potential improvements that require a facility solution and the associated costs of such solutions.
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Identify patient outcome improvements and quantify these. Identify family nutrition support requirements. Conduct a return on investment (ROI) analysis to request approval and funding for additional building features.

Goal 1-6: Improve Patient Sleep and Rest
Literature Review
Rest and good sleep are essential to timely patient recovery and quality of life. Unfortunately, the adage that you do not go to a hospital to get sleep or rest continues to be true. Noise and poorly planned patient-care routines represent two of the most common reasons why patients have trouble sleeping. Multiple studies identify that most noise stems from the presence of another patient and the resulting noise from the roommate(s) and their equipment, care team and visitors. Patient satisfaction results reveal that patients in a single-bed room are vastly more satisfied with the “noise level in and around [their] room”.43

Recommended EBD Features or Responses
* Single-Bed Rooms Single-bed rooms are the most effective EBD response to reduce noise, setting the stage for better rest and sleep. * Reduce or Eliminate Loud Noise Sources Plan for noiseless paging and alarms. No overhead announcing systems should be routinely planned or used. Educate staff, patients and visitors about noise and arranging care to maximize sleep. Achieve World Health Organization (WHO)-recommended noise decibel levels. Comfortable Beds and Bedding Comfort should be an important selection criterion for beds and bedding during the equipment acquisition process.

Future Study Opportunity
Patient Satisfaction with Sleep and Rest Current patient satisfaction with the quality of rest and sleep in MHS facilities is unknown. Inpatient satisfaction surveys could be modified to include a question about this important patient outcome. Depending on the results, a community of practice may need to be formed to address identified problems and to consider facility solutions and clinical practice modifications.

Goal 1-7: Decrease Exposure to Harmful Chemicals
Literature Review The Green Guide for Health Care recommends guidelines for construction materials and furnishings with the objective of minimizing indoor air contaminants that are odorous, potentially irritating and/or harmful to the comfort and well-being of installers and
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occupants.44 The Green Guide draws upon several sources for these guidelines including: the South Coast Air Quality Management District (SCAQMD) Rules #1168 and #1113, Green Seal Standard GC-36, California Prop 65, California Air Resources Board List of Toxic Air Contaminants, and California 01350. Recommended EBD Features or Responses Use 100% Lead- and Cadmium-Free Roofing, Wiring and Paint Install Low-Mercury Florescent Lamps Use Materials that are Low Emitters of VOC (volatile organic compounds) and PFC (perfluorocompounds) Use Materials with no PBDE (polybrominated diphenyl ethers) or Phthalates Use Materials with No Added Urea-formaldehyde Resins. Minimize use of furniture and furnishings that contain: PBDE, PFOA, urea-formaldehyde, phthalate, and plasticizers. The Green Guide recommends that at least 40% of the annual purchases (by cost) meet the standards (i.e., contain no more than one of the compounds listed above). Future Study Opportunities Green Guide Adherence across Each Phase of the Facility Life Cycle Performance and Management Model The degree to which the Green Guide recommendations are adhered to in the MHS at each phase of the Facility Life Cycle Management and Performance Model—but particularly in the sustainment phase—is not known.

EBD Principle 2: Improve the Quality and Safety of Healthcare
The Center for Disease Control and Prevention estimates that hospital-acquired infections (HAI, a.k.a. nosocomial infections) account for 1.7 million infections, 99,000 deaths and $5 billion in excess healthcare costs each year, including longer hospital stays, additional surgeries and more staff hours.45 In 2005, the state of Pennsylvania found that, in their 168 hospitals, there were 19,154 cases of infection–or 12.2% per 1,000 cases–which accounted for 394,129 hospital days and $3.5 billion in hospital charges. A comparison of cases with and without infection is provided below:46
Case Type HAI Without HAI Number 19,154 1,550,010 Mortality 2,478 12.9% 36,238 2.3% Average Length of Stay 20.6 days 4.5 days Average Charge $185,260 $31,389

MHS hospitals that receive war wounded have been particularly challenged by antibioticresistant acinetobacter baumannii, klebsiella pneumoniae, pseudomonas aeruginos and

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staphylococcus aureas infections in addition to the more common HAI. Research is underway to understand the high rate of current infections associated with casualties in the war on terrorism.47 Three improvement goals—one for each potential source of infection—are provided below, along with additional goals to reduce medication errors, prevent patient falls and to reduce noise stress and improve speech intelligibility. Expected patient, staff and resource outcomes associated with achieving the six goals associated with improving the quality and safety of healthcare include: Reduce the number of HAI as well as associated patient morbidity, mortality and cost. Reduce the number of and associated costs for staff with HAI. Decrease the number of medication errors, patient falls and associated costs. Improve patient sleep and rest by achieving WHO-recommended noise decibel levels.

Goal 2-1: Reduce Airborne Transmitted Infections
Literature Review
The hospital-based transmission of airborne pathogens can occur in three main ways: (1) when an environmental reservoir is disturbed (e.g., Aspergillus), (2) from person to person in the form of droplets in the air (e.g., SARS); and (3) from residual droplets that can remain indefinitely suspended in the air and can be transported over long distances (e.g., tuberculosis).48 A number of studies confirm the relationship between the above parameters and the occurrence of airborne transmitted infections. Several studies provide convincing evidence that use of HEPA (High Efficiency Particulate Arresting) filtration at the 99.97% rate reduces infection incidences for immunocompromised and other highrisk patients. One study found that bone-marrow transplant recipients were found to have a tenfold greater incidence of nosocomial Aspergillus infection compared to other immunocompromised patient populations when they were cared for in beds outside of a HEPA-filtered environment.49 Their findings were corroborated by Hahn et al (2002) who studied two units in which patients with hematologic malignancies received care. Patients on the bone marrow transplant unit with a fully HEPA-supported environment experienced only one Aspergillus infection versus nine patients on the unit without HEPA, seven of whom died.50 Passweg, et al. (1998) showed statistically significant mortality differences for allogenic bone marrow transplant leukemic patients for those who received their care in HEPA filtered rooms.51 Northwestern Memorial Hospital, an academic medical center in Chicago that provides many services for vulnerable patients, provided HEPA filtration throughout the entire hospital – and has not experienced a single Aspergillus infection since the hospital opened in 1999.52 Current AIA criteria recommend the use of HEPA in surgical areas, burn ICUs and those protective environments where severely immunocompromised patients receive care. Severely immunocompromised patients include bone marrow transplant patients, patients with severe neutropenia, and pediatric AML patients. DoD Criteria specifies HEPA for positive isolation rooms and specialty operating rooms, to include: cardiothoracic surgery, heart lung pump room, neurosurgery and orthopaedic surgery.

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There are reports of some non-healthcare institutions using ultraviolet germicidal irradiation (UVGI) to mitigate airborne transmitted viruses. Menzies et al (2003) reported on the effects of UVGI on drip pans and cooling coils within ventilation systems for office buildings of 771 office workers in Montreal. The results showed 99% reduction of microbial contamination on irradiated surfaces within the ventilation systems with substantially fewer work-related mucosal, respiratory and overall symptoms.53 No Center for Health Design Pebble Projects are currently studying UVGI. Ventilation is another important means to control the level of pathogens in the air. A recent study by members from the Imperial College of London (2007) in 8 hospitals in Lima, Peru, found that old hospitals with high ceilings and large windows (with open doors and windows) averaged 40 air exchanges per hour, which reduced the probability of institutionally-acquired TB infection using the Well-Riley equation to 11% as compared with 39% of patients cared for in mechanically-ventilated rooms with 12 air exchanges per hour.54 Current recommended AIA and DoD ventilation rates vary across different patient-care areas of a healthcare facility.

Recommended EBD Features or Responses
* Single-bed Rooms Single-patient rooms reduce the proximity of contagious patients to non-infected patients. * Provide HEPA Filtration Provide HEPA (99.97%) filtration in those areas where vulnerable patients receive care, such as the Emergency Department, chemotherapy infusion rooms, hematology-oncology inpatient units, operating rooms, and ICU-IMCU rooms. Ensure that HVAC Systems are Well-Maintained and Operated Construction and Renovation Control Measures Ensure that effective control measures are used during construction and renovation. Such measures include: using portable HEPA filters, installing barriers between the patient-care and construction areas, using negative pressure in construction/renovation areas relative to patient-care spaces, and sealing patient windows.55

Future Study Opportunities
Reduce MHS Airborne HAI Infections Currently, HEPA filtration is routinely planned for specialty MHS operating rooms and positive pressure rooms. Recommend that a community of practice—consisting of infectious disease and infection control clinicians, patient safety and performance improvement staff, along with healthcare facility experts—be established to: Determine if airborne nosocomial infections are a problem and if so, what patient population is at risk. Identify additional locations where HEPA filtration should be added to potentially improve patient outcomes. Target specific outcome improvements and quantify savings.

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Conduct a return on investment analysis to request approval and funding to add additional HEPA filters, as appropriate. HEPA Efficacy in Asymmetric Warfare: Biological Agents The military has a unique role during contingency operations. Recent employment of asymmetric warfare techniques increases the potential for use of other technologies, such as dirty bombs with biological agents. Study is needed to understand the role hospital HEPA environments might play in successfully responding to such contingencies. Evaluate Ventilation Exchange Requirements for Severely Immunocompromised Patients Examine the current criteria for ventilation, particularly for severely immunocompromised patients, in the form of air exchange rates as a second variable, using the same study process described for HEPA filtration. Use of UV to Mitigate Airborne Transmitted Viruses The military has particular interest in understanding any positive role that UV technology might play with regard to reducing the number of airborne transmitted viruses. In the past, basic training environments have been plagued by varicella and influenza outbreaks, and world-wide missions make warriors vulnerable to SARS and other viruses. Infected warriors may require hospitalization, which further enhances a need to understand the role UV plays in mitigating airborne transmitted viruses in MHS facilities.

Goal 2-2: Reduce Infections Spread Through Contact
Literature Review
Inadequate hand washing on the part of healthcare workers accounts for most hospitalacquired infections. Hand washing compliance rates of 15-35% are typical, with the lowest rates found among physicians and nursing assistants.56 Some studies have found that there may be environmental approaches to improve hand washing compliance, specifically the location, accessibility and number of hand washing sinks and alcoholbased hand cleaner dispensers. However, there is less clarity about the ideal location of these devices and sinks within and outside of the patient room to achieve the best results. Further human factors engineering analysis is needed to understand how the location of sinks and devices plays a role to improve staff compliance, especially when coupled with improved staffing and staff education programs. AIA recommends hand-washing stations in each of the following clinical spaces. DoD criteria closely mirror these recommendations. Patient rooms (in addition to one in the patient toilet/bath) Medication station Nourishment area Clean workroom (if used for preparing patient items) Soiled workroom Nurse station (convenient to the nurse station) Exam rooms Multiple-bed areas in the ED (one per four beds)

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Imaging rooms (in [nearby for MRI] rooms where staff physically handle patients) PT and OT (in each treatment space) Nursery (one per eight infant stations) NICU (within 20 feet of each infant station in multiple-station areas) Microbiologically-contaminated surfaces represent another means by which infections are spread by contact. High-contact surfaces need to be cleaned and disinfected more frequently than minimal contact surfaces, which means that the selection of materials for floors, walls, ceilings, furniture, furnishings and equipment with regard to ease of cleaning is a key consideration. According to Collins (1988), the number and type of organisms on a surface depends upon: the number of people in the environment amount of moisture present amount of activity presence of material capable of supporting bacterial growth rate at which organisms suspended in the air are removed and type of surface and orientation (horizontal or vertical), with counts from smooth intact walls and ceilings with lower counts.57 Copper is germicidal; surfaces have been shown to actually decrease the number of bacteria over time. Brass (a copper alloy) doorknobs disinfect themselves in about 8 hours; stainless steel and aluminum never do. (And the more they tarnish, the quicker they kill bacteria!) Using copper or brass for door handles, faucets, and other highcontact surfaces therefore may be an effective way to minimize the spread of infection and should be studied in healthcare environments as a means to decreasing HAI transmitted through contact.58,59

Recommended EBD Features or Responses
* Single-bed Rooms Single patient rooms are easier to decontaminate than multi-bed rooms. Sink and Hand-washing Stations Both AIA and DoD criteria specify rooms in which sinks and hand-washing stations should be located. What is not clear is where the ideal location for both to improve staff compliance (see Future Study Opportunity below). Frequent Cleaning of High Contact Surfaces. Ensure that the housekeeping contracts specify those surfaces that require frequent cleaning. Evaluate Building Materials and Furnishings with Regard to Ease of Cleaning. Query manufacturers with regard to ease of cleaning and any associated infection-related concerns.

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Future Study Opportunities
The Ideal Location for Sinks and Hand Washing Dispensers It is not clear how many sinks or alcohol-based hand-cleaner dispensers are needed, nor the ideal location of these devices to positively contribute to improved staff compliance with hand washing. The MHS could develop such a study as a component of an MHSwide initiative to reduce HAI to identify the preferred location for alcohol-based hand cleaner dispensers to stimulate staff compliance. Use of Copper Alloys for High-Touch Surfaces The germicidal properties of copper (and its alloys, such as brass) have long been known, and the effect on Methicillin-resistant staphylococcus aureus and other infectious bacteria (including E. coli) has been studied in the laboratory. However, only limited studies have been done in the healthcare environment. The MHS could study the effect of using these materials for high-contact surfaces in areas where patients are particularly vulnerable to infection, such as the ICU or ER.

Goal 2-3: Prevent Waterborne Infections
Literature Review
Regular cleaning, maintenance, and testing of water systems and point-of-use fixtures is important for preventing the spread of waterborne infections such as Legionnaires’ disease. Water systems must be designed to minimize stagnation and back flow as well as provide temperature control to prevent bacterial growth.60 Decorative fountains are increasingly found in healthcare facilities as important wayfinding features and as positive distractions to reduce patient and staff stress. Although there has been some concern by infection control staff that these features may cause nosocomial infections, no documented cases exist.61

Recommended EBD Features or Responses
Avoid Decorative Water Fountains in High-Risk Patient Care Areas Even though there are no documented cases, it is prudent to avoid any risk for immunocompromised patients. Ensure that Fountain Water Temperature is Cold and Fountains are Well-Maintained Use Proper Water Treatment Practices Adhere to minimum and maximum water temperatures augmented by chlorine treatment, or copper-silver ionization and UV light as appropriate. Regularly Maintain and Inspect the Water Supply System To minimize stagnation and back flow and for temperature control, provide regular maintenance and inspection—or consider using a looped water system to minimize maintenance requirements. Regularly Clean and Maintain Faucet Aerators to prevent and control for Legionella.

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Goal 2-4: Reduce Medication Errors
Literature Review
Medication errors are multi-factorial events for which environmental variables may play a role. Ulrich et al (2004) found studies which suggest that lighting levels, frequent interruptions or distractions during work, and inadequate private space for performing work can be expected to worsen medication errors.62 However, only limited evidence associated with improving the work environment for medication preparation, dispensing and administration was found by the Institute of Medicine’s recent review of existing research.63 There are some indications that family presence in inpatient rooms may help to reduce medication errors. Clearly, more research is needed.

Recommended EBD Features or Responses
Assess the Adequacy of Lighting Levels in Staff Work Areas – especially the lighting in (the pharmacy and nursing) areas that support medication preparation, dispensing and administration. The need for light for visual task performance increases with age. Provide Private Space for Work to minimize interruptions and distractions. Future Study Opportunities Optimal Lighting Requirements for Medication Administration Activities More research is needed to understand the optimal lighting requirements for supporting medication administration and staff performance. Impact of Family Presence on Medication Errors The impact of family member presence on medication errors for those patients cared for in single-bed rooms with family support space versus those patients cared for in multibed rooms without family support space is worth studying. Impact of Decentralized Nursing Support on Medication Errors Decentralized nursing support is planned for the New WRNMMC and Fort Belvoir Community hospitals, to include automated medication dispensing for routine and scheduled medications. It is not known what impact this will have on medication error rates.

Goal 2-5: Prevent Patient Falls
Literature Review There is extensive literature addressing how to prevent patient falls and the associated patient physical injury, psychological effects, and increased length of stay, all of which translate to cost; $32.4 billion is projected by 2020.64 Brandis (1999) reported that 43% of patient falls occurred with transfers to and from the bed or chair and 30% occurred with toileting activities.65 Successful fall prevention programs require a comprehensive approach that includes mechanisms for identifying high-risk patients, management strategies, staff training and equipment use, such as patient movement monitors.

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However, the verdict remains out on the EBD features and responses most likely to contribute to the reduction of patient falls. Many researchers are focused on mitigating the fall risk associated with unassisted patients moving from the bed to the bathroom, through the so called, “no grab” zone. Some of the EBD strategies under scrutiny include: Locate the bathroom on the same wall as the head of the bed, with grab rails from the bed to the bathroom for patients to hold onto as they steady themselves. Use a pod concept of design to increase nursing personnel observance of and proximity to the patient. Use single-patient rooms, providing significant space for family members who can assist patients in their movement. Place and adequately size bathroom doors to facilitate patient movement, especially when encumbered by equipment, such as IV poles. Use flooring materials with less slippery qualities.

Recommended EBD Features and Responses
* Single bed Rooms Single-patient rooms invite the presence of more family, who can then assist with patient movement. Decentralized Nursing Support Using a Pod Concept Provide charting space, clean materials and linen, soiled collection and automated medication dispensing close to patient rooms, using a pod configuration to provide a cockpit-like approach. The recommended ratio of beds per pod is 2 beds in the ICU/IMCU units and 4-8 beds in acute medical/surgical, pediatric and obstetric units. Most of the needed supplies and medications are available just outside the patient door and the nurse can chart or coordinate care without returning to a central nurses’ station. The result is that nursing staff are more readily available to help move patients because they have less reason to leave the patient care area. Bed Features to Reduce Falls Bed selection processes should consider those with features to reduce the risks associated with patient falls such as monitoring patients and sounding an alarm when a patient attempts to leave the bed unassisted.

Future Study Opportunities
Reduce Patient Falls in MHS Hospitals Patient falls are also a problem in MHS hospitals. With the Patient Safety and Performance Improvement communities, the impact of recommended EBD features in new MHS hospitals combined with other fall prevention initiatives should be studied with regard to reducing the number of patient falls. Impact of Decentralized Support on Patient Falls The impact of decentralized support on the incidence of patient falls in MHS hospitals is not known. Perhaps a present unit could be configured with the decentralized support described and then evaluated with regard to patient falls and other key safety and quality

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patient outcomes as part of the transition planning activities for the NCA projects. Another feature to study might include the use of overhead cabinets versus mobile supply carts. An ICU unit under renovation in the current WRAMC will include decentralized support and could be used for this study.

Goal 2-6: Reduce Noise Stress and Improve Speech Intelligibility
Literature Review
Hospitals are terribly noisy. The World Health Organization (WHO) recommends decibel levels no more than 35 during the day and less than 30 at night. It is safe to say that very few hospitals comply with WHO’s recommendation. One hospital in the Bronx with a noise-reduction plan in place maintains decibel levels of about 65. This represents a 28% reduction for them, but still far exceeds the WHO recommendations.66 BuschVishniac et al (2005) has examined data from hospitals over the past 45 years, which shows increasing noise levels both during the day and at night.67 In fact, peak noise in a patient’s room at the change of shift has been measured at 113 dB, equivalent to the sound from a jack hammer!68 The impact on patients is significant. Loud noises cause several physiologic responses: increase blood pressure and pulse, increased respiration, and decreased sleep. There are some studies which indicate that noise may negatively impact healing. One study with cataract patients found that patients stayed significantly longer during a noisy period associated with construction.69 Patient rehospitalization was higher for post acute myocardial infection patients in one Swedish hospital during bad acoustic conditions, reflecting important detrimental physiological effects on rehabilitation.70 Speech intelligibility is essential in patient care delivery because many patient care activities require verbal exchanges that must be accurately heard to avoid mistakes. In addition, many emerging digital systems use speech recognition systems, which require a signal-to-noise ratio of +15 dB(A) to ensure accuracy.71 Less is known about the impact of noise on staff stress and staff performance. One study found that noise-induced stress was related to burnout and emotional exhaustion in critical care nurses.72 Joseph and Ulrich (2007) provide an excellent overview of a number of studies that did not find a relationship between performance and different sound conditions for surgeons and anesthetists.73 Recommended EBD Features and Responses Resolving noise issues requires a comprehensive approach that includes staff education and patient care management practices, such as quiet hours, to maximize patient rest and sleep. Specific EBD features include: * Single-bed Rooms Most noise originates with the presence of a roommate.

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* Install High-Performance Sound-Absorbing Acoustical Ceiling Tiles This type of tile shortens reverberation times and reduces sound propagation thereby speeding the decay of sound.74 These tiles should be used in all new construction and to replace existing tiles during routine facility sustainment activities.iv Remove Loud Noise Sources Typical offenders include overhead paging and personal pagers. Locate Noisy Equipment Away from Patient Rooms The most notorious equipment offender is the ice machine. Ensure All Patient Care Rooms Have Walls that Extend to the Support Ceiling Many patient care areas include multi-patient spaces, which are separated by a curtain – very common in the Primary Care Clinic Treatment rooms and Post Anesthesia Care Units. For all of the reasons described above, this creates a noisy environment, which may significantly contribute to poor patient outcomes. The walls need to extend all the way up to the structure above in order to fully block the noise between patient rooms and public spaces (e.g., hallways). Use Carpet and Rubber Floors Where Appropriate Carpet absorbs sound, but this must be weighed with infection control issues in areas where the risk of spilled patient fluids exists. Hallways may be a reasonable area for carpet use.

Future Study Opportunities
Evaluate the Practice of Replacing Existing Ceiling Tile with High-Performance Sound Absorbing Acoustical Ceiling Tile and Its Impact on Patient Outcomes Select any current inpatient unit with old ceiling tile and replace it with the recommended tile and evaluate patient rest, sleep, satisfaction, perception of pain and need for medication before and after replacement. Evaluate the ROI of extending walls with proper sound mitigation treatment to the underside of the structure above. Evaluate the effect of using curtains in patient rooms as additional sound absorbers. Weigh this benefit (and the ability of the patient and family to control glare and light) against potentially increased costs for cleaning.

EBD Principle 3: Enhance Care of the Whole Person (Contact with Nature & Positive Distractions)
The central tenet of EBD is patient-centered and family-focused care. Patients and their families do not spend time at hospitals because they are bored and seeking entertainment. They are there because they are ill or injured or concerned about preventing illness and ultimately, improving their health. They enter an environment that is often confusing,

iv

In response to questions about cleanability: Rather than cleaned, most ceiling tiles just get replaced on a regular sustainment cycle.

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uses a separate language, and in which painful procedures occur and frightening and overwhelming information is given. Expected patient, staff and resource outcomes associated with achieving the EBD goal associated with decreasing patient and family stress include: Support healing with less depression, alleviate pain, improve sleep and circadian rhythms; all of these result in decreased use of pain medication and patient lengths of stay as well as increased patient satisfaction.

Goal 3-1: Decrease Patient and Family Stress
Literature Review Most of the preceding goals addressed how to reduce or eliminate stressful aspects associated with the hospital experience. The focus of this goal is to provide positive distractions that help patients and family members cope with those stressful events that cannot be eliminated. Positive features to mitigate stress include, but are not limited to access to nature and healing gardens, artwork and music. The scope of this report does not permit a detailed summary of the more than 350 rigorous studies relevant to patient stress and the physical environment identified by Ulrich et al (2004).75 Salient highlights include the fact that numerous studies demonstrate improvement in patient physiological measurements and perceived stress when patients are able to view nature (as opposed to those without nature views). Several studies actually demonstrated the ability of nature views to mitigate pain. Diette et al (2003) showed that flexible bronchoscopy patients who were able to look at a ceiling mounted nature screen and listen to nature sounds experienced less pain than those patients who had a blank ceiling view.76 Ulrich (1984) found that abdominal cholecystectomy surgery patients whose windows provided views of trees—rather than a brick wall—required less narcotic pain medication and experienced a shorter hospital stay, and they had fewer negative evaluative comments in nurses notes.77 Technology may provide alternate ways to achieve nature access when patients are being cared for in interior spaces, including such programs as the Continuous Ambient Relaxation Environment (CARE) Channel displayed on flat screen TVs (providing 60 hours of nonrepetitive nature images), or by providing appropriate music for different areas.78 Visual art can also reduce patient stress and reduce pain, if care is taken to avoid abstract, surreal or negative images, which can cause a negative patient response.79 Views of nature are the most successful in relieving stress for diverse populations.80 Dental patients were less stressed on those days when a large nature mural was present in the waiting room compared to the days when the wall was blank.81 Music provides another positive distraction that can reduce anxiety, provide distraction during uncomfortable or painful procedures, provide meaningful stimulus and promote rest and sleep.82 Music can also mitigate patient stress, particularly if the patient is allowed to select the type of music.83 Sedative music to augment other interventions is characterized by no accented beats, no percussive characteristics, a slow tempo and smooth melody.84 Music has been shown to positively reduce physiologic responses,

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anxiety and confusion for a broad range of patients, to include those being mechanically ventilated, women undergoing Caesarean delivery, mothers caring for NICU infants and elderly patients undergoing elective hip and knee surgery.85, 86, 87, and 88

Recommended EBD Features and Responses
*Single-bed Rooms Single-patient rooms facilitate greater individualization of the patient’s environment. Provide Secure Access to Nature Landscape designers employ many features that can provide patient access to nature, including healing gardens, planted atrium spaces, courtyards, and terrace gardens, to name a few. Provide Positive Distractions – Art, Music etc. Provide Multiple Spiritual Spaces and Haven Areas Current DoD criteria include a chapel and consultation rooms, which—combined with good landscape design features, such as healing gardens—can provide spiritual and haven areas.

Future Study Opportunities
MHS Patient Satisfaction with Access to Nature Positive Distractions Identify current patient satisfaction with regard to access to nature and positive distractions and identify those elements that positively and negatively contribute to the care of the whole person.

EBD Principle 4: Create a Positive Work Environment
The ability to attract and retain a quality workforce will continue to be an essential ingredient for healthcare facility success. The challenge will be greater though, as babyboomer demand for care increases, exacerbating existing healthcare workforce shortages. Patient-centered care dynamics will reshape the care team as family members assume a more active role in patient care support. The environment, along with organizational culture, the physical demand associated with clinical practice, evolving technology integration, workforce adequacy, and recognition for care excellence all contribute to job satisfaction and ultimately care excellence and staff retention. Expected patient, staff and resource outcomes associated with achieving the four goals associated with creating a positive work environment include: Decrease staff and patient injuries associated with patient handling and consequent Federal Employee Costs (FECA). Provide more time caring for patients rather than time walking, retrieving supplies and coordinating care. Decrease staff stress, fatigue, burnout and turnover; and increase staff satisfaction, morale and retention by creating better work ergonomics and environment. Decrease errors that result in increased length of stay, patient dissatisfaction, morbidity, mortality and litigation.

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Goal 4-1: Decrease Back Pain and Work-related Injuries
Literature Review Back strains and sprains account for 44% of all injuries to nursing staff in hospitals that result in lost workdays, and account for 10.5% of back injuries nation-wide.89 The combination of heavier patients and aging nurses will only worsen this existing problem. Nelson and Baptiste (2006) identify that nursing staff are consistently among the top 10 occupations for work-related musculoskeletal disorders with 8.8 incidences per 100 staff, a low estimate because of chronic underreporting.90 This is no surprise since they estimate that the average nurse typically lifts 1.8 tons of cumulative weight during a shift! A comprehensive solution to the problem involves the creation of a Zero-lift program, supported by appropriate equipment (such as ceiling-mounted patient lifts) and implemented by informed staff and engaged leaders. The American Nurses Association has outlined the expected improved outcomes associated with a Safe Patient Handling Program that incorporates the use of lifts:91 Reduction in the incidence and severity of injuries to staff Decrease in patient falls, skin tears and abrasions Increased patient comfort, security and dignity during transfers Better patient mobility and independence Enhanced patient toileting outcomes and increase in continence Improved job satisfaction and staff efficiency Enhanced compliance with JCAHO standards. Although portable patient handling devices are available, Nelson and Baptiste (2004) noted several barriers to their use:92 Patient aversion to the equipment Unstable equipment or operationally difficult to use Patient weight limitations Time constraints Inadequate number of lifts available in the patient care areas Storage issues (e.g., equipment is located in an inconvenient place) Space restrictions to control the equipment Difficult to maintain and clean No training on the devices on units with high staff turnover rates Joseph and Fritz (2006) provide an excellent summary below of the steps associated with moving a patient contrasting use of a floor versus ceiling lift, clearly indicating why the floor model is less useful.93

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Floor Lift 1. Decide if lift is needed 2. Decide which lift is needed 3. Go get the lift 4. Hopefully can find it and don’t have to wait 5. Move lift to patient room 6. Move the furniture out of the way 7. Position lift 8. Lift patient 9. Move lift out of the way 10. Care for patient 11. Return lift to its home 12. Go back to patient or on to next patient

Ceiling Lift 1. Decide if lift is needed 2. Put sling under patient 3. Lift patient 4. Care for patient 5. On to next patient

Many of the barriers cited above are removed with the use of ceiling-mounted lifts. Research has demonstrated a reduction in staff injuries and associated medical and compensation costs. One hospital was able to decrease the number of staff injuries associated with patient handling of ICU and neurology patients from ten over 24 months to three over 36 months after ceiling-mounted patient lifts were installed. The result was an 83% reduction in annual costs associated with patient-handling injuries.94 An extended care facility in British Columbia found a 68% reduction in compensation costs in a unit with ceiling mounted lifts versus a 68% increase in compensation costs for another unit without such lifts over the same time period.95 In the British Columbia study, an assumption about pre-intervention injury costs, economic pay-back for the ceiling mounted lifts was projected to be 0.8 years, given increased injury costs, or 2.5 years if associated injury costs remained stable.96 Legislators are also interested in the problem. Representative Conyers (D-MI) has introduced HR 378, Nurse and Patient Safety & Protection Act of 2007, which specifies a series of actions and standards to reduce injuries to patients and staff. Section 3 of the Bill directs health care facilities to “ensure that safe lifting mechanical devices shall only be used by registered nurses.”97 Recommended EBD Features and Responses * Install Ceiling-Mounted Lifts Ceiling-Mounted Lifts should be provided in those rooms where patients are likely to require lifting or movement—such as ICU/IMCU rooms, Operation Rooms, Emergency Department Trauma Rooms, and some portion of medical/surgical and pediatric rooms— as part of a comprehensive Zero-Lift program. Use Softer Floors Consider the use of softer floors in those areas where lengthy staff standing routinely occurs. Redfern and Cham (2000) has shown a decrease in lower extremity and low back pain for workers who are on their feet when standing on softer floors, such as rubber.98

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Ergonomically Evaluate Work Areas Some specific work areas associated with staff injury include operating rooms, where staff movements are constrained and prolonged, and at computer work station areas for all healthcare staff members with a focus on posture, computer readability and visual fatigue.99 Future Study Opportunities Reduce Patient and Staff Injury Incidence and Severity Inclusion of the above-recommended EBD features represents just one element of a comprehensive MHS Zero-Lift policy. Such a program should be developed and then studied with regard to the costs of mitigating injuries contrasted with negative patient outcomes to include injury and associated increased care costs and litigation, as well as injured staff costs associated with medical care, compensation, sick days, restricted duties, and retention. Ergonomic Evaluation of Work Areas There are many healthcare environment areas that require further ergonomic evaluation and study to understand what features in the built environment will reduce staff injury. Optimal height of work surfaces within nurse stations (sitting versus standing), for example, should be examined. Needle Stick Injuries Needle sticks are another common staff injury, which universally require medical evaluation and very often, prophylactic treatment to avoid potential life-threatening consequences. The physical environment may play an important role, specifically as it relates to the location and use of sharps disposal boxes within a standardized room configuration.

Goal 4-2: Reduce Staff Fatigue
Literature Review Inpatient nursing care delivery is physically demanding, worsened by the fact that most inpatient units centrally organize charting, supplies, medications and other support elements, necessitating frequent trips by nurses. One study of nursing behavior in a 233bed teaching nursing home found that 28.9 percent of nurse time was spent walking.100 Actual unit configuration was found to significantly impact walking time in a study by Shepley et al (2003), where nurses on a radial unit walked 4.7 steps per minute compared with 7.9 steps per minute on a rectangular unit.101 Note: In addition to changing the physical environment, better use of medical technology (e.g., electronic medical records, care coordination software, computerized physician order entry, etc.) can decrease both walking and waiting times for staff.102 DoD Space Criteria Guidelines were recently modified, in 2006, to allow for inpatient nursing pods or modules that provide decentralized support including: nurse sub-stations, automated medication dispensing units, clean supply and linen carts, and a soiled collection cart. Typically, this cockpit-like approach is provided for every 2

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ICU/IMCU/LDR beds and every 4-8 acute medical/surgical, pediatric and obstetric beds. The anticipated result is that the nursing team will remain proximate to the patients, thereby facilitating more time in direct patient care, which will result in fewer patient falls and medication errors and less staff fatigue and greater work satisfaction. However, Joseph (2006) suggests that attention must be given to the change in staff interactions and consequent staff communication effectiveness and satisfaction associated with this decentralized process.103 Recommended EBD Features and Responses Decentralize Staff Support Spaces Locating staff support spaces such as supplies and charting space next to or in patient rooms should reduce staff walking, providing more patient care time and greater staff satisfaction. However, the space should be designed with privacy to minimize distractions that can result in errors. Provide Windows in Staff Break Rooms As is true with patients, access to natural light may help staff with circadian rhythm adjustment, thereby improving staff fatigue. Natural light costs nothing once the window is provided.

Impact of Natural Light versus Artificial Light on Staff Mood and Performance Some studies have shown that staff exposure to natural light has a positive impact on their work experience. More work is needed to understand the importance of natural light to staff and specifically any impacts on staff performance, especially as the healthcare workforce ages. Impact of Different Lighting Conditions on Staff Work Performance Providing quality healthcare involves multiple complex tasks: medication preparation and administration, conducting invasive and non-invasive procedures, and documenting care. Several studies summarized in Joseph’s 2006 article on light showed that exposure to intermittent bright light during the night shift is effective in adapting circadian rhythms of night-shift workers.104 Additional research is needed to understand the ideal light level for a variety of error-prone tasks by workers of varying ages. Future Study Opportunities Decentralized Staff Support Areas Planned for New Community Hospital at Ft. Belvoir. Decentralized staff support is planned for the New Community Hospital at Fort Belvoir and some units at the New Walter Reed National Military Medical Center at Bethesda. The decentralized support includes: charting, clean supplies and clean linen, soiled collection and automated medication dispensing for routinely scheduled medications. Efforts should be made to understand the impacts of this investment on patient and staff outcomes, to include staff fatigue. Patients may provide important information to consider in design. In addition, there may be increased pharmacy and logistic staff costs associated with packaging and distributing medications and materials to more locations on each unit.
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Supplies Location Providing supplies in the patient room can be effected without interrupting the patient by having cabinets in the corridor walls of the rooms that open from both inside and outside the room. The effects on caregiver and logistical staff exhaustion as well as on patient satisfaction could be measured.

Goal 4-3: Increase Team Effectiveness
Literature Review Providing quality healthcare is simply one of the most complex work experiences – one that depends on effective communications across a multidisciplinary team to achieve the best patient outcomes. Joseph (2006) states that “Communication breakdowns occur frequently in healthcare practice due to the physical environmental, organizational, and technological infrastructure in healthcare facilities that focuses on supporting the individual rather than team efforts.”105 Space characteristics that support interactive team work include: Visual connections to facilitate information seeking and interaction Flexible workspaces Smaller unit size to foster interaction Neutral spaces that minimize professional and status hierarchies Optimizing unit adjacencies that collectively provide care for unique populations can improve team communication and collaboration. Some of those specialty care centers include: musculoskeletal, cancer, child, women and behavioral. Using musculoskeletal as an example, collocating the orthopedic, podiatry, physical therapy, occupational therapy and supporting radiology services increases the ease of staff communication by decreasing physical distance, and takes the patient off the “assembly-line” model of care often seen today. Recommended EBD Features and Responses Provide Different and Flexible Types of Spaces for Interactive Team Work Current inpatient DoD Space Criteria provide space for a workroom, which is intended for use by the whole team. Likewise, conference rooms, nurse’s stations, consultation rooms, staff lounges, staff support space in a pod configuration and other generic staff spaces throughout a hospital are intended to support spontaneous team interaction. Optimize Unit Adjacencies with Care Centers Collocate teams who each play a vital role in caring for unique populations to create a patient-focused approach that should also improve staff communication and collaboration. This planning approach was used to program the New Fort Belvoir Community Hospital and WRNMMC projects. Future Study Opportunities Provider and Patient Satisfaction Using a Care Center Approach Both NCA projects provide an opportunity to study changes in provider and patient satisfaction and errors using a care center approach. A number of care centers exist today

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at WRAMC and NNMC and could be studied with regard to team effectiveness and patient satisfaction. Smaller Unit Size to Foster Interaction DoD Space Criteria provides specific recommendations for the number of beds by specific unit type. At the New WRNMMC, a number of the planned medical/surgical units are larger than the DoD recommendation not to exceed 36 beds because of funding and physical constraints. A pod design concept with decentralized support was planned to mitigate some of the challenges inherent in large units. Likewise, many civilian hospitals also are building large units (40 beds) with pod support. Understanding and applying civilian lessons learned about team effectiveness with regard to this approach is an important transition planning undertaking. Obviously, optimal communications and logistics processes must also be combined with changes to the built environment.

Goal 4-4: Eliminate Noisy, Chaotic Environments
Literature Review This goal particularly addresses the impact of noisy, chaotic environments on staff and represents the complementary goal to the patient-centered goals associated with improving patient sleep and rest and reducing noise stress. Although Joseph (2006) found few studies that addressed the specific relationship between noise and staff health and performance, there were several studies that suggested a relationship between noiseinduced stress and staff burnout.106 Morrison et al (2003) found that pediatric intensive care unit noise contributed to staff stress and annoyance and produced higher pulse rates and tachycardia in staff. 107 Toft and Dillion (1988) found that noise-induced stress was related to burnout and emotional exhaustion in critical care nurses regardless of their individual intrinsic sensitivity to noise.108 Recommended EBD Features or Responses In addition to the recommendations made under the patient-centered goals associated with reducing noise that were described earlier, Adequate Space for Quiet, Private Work To minimize distractions and interruptions, provide a quiet space to work. DoD Space Criteria includes a number of rooms that can provide the desired environment if designed appropriately: workrooms, consultation rooms, decentralized sub-nursing stations, and conference rooms. Future Study Opportunities NCA MTF Noise and Impact on Staff Stress, Performance and Retention. There is little baseline information about the impacts of existing NCA stressful environments, like the ICUs, on staff. Replicating Topf and Dillon’s study may provide important insights for the new facilities, particularly with regard to staff training and developing policies and guidelines.

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A hospital in the Bronx has piloted a program to quiet one floor, and their decibel levels have been reduced by 28%. In addition the sound-absorbing ceiling tiles and curtains, the program relies on posters, buttons given to each patient, staff and visitor and proper maintenance of potentially loud equipment.66 The educational component probably has as much impact as the environmental measures.

EBD Principle 5: Design for Maximum Standardization, Future Flexibility and Growth
Most military healthcare facilities remain in the DoD inventory for fifty years. Consequently, each Medical MILCON investment requires a dual approach to first satisfy the anticipated healthcare demand when the facility opens and then to anticipate those aspects of healthcare delivery most likely to change, for which future alterations and additions may be needed. Most health care facilities experience seven or more remodels or changes during the life of the facility.109 Careful stewardship of limited MHS infrastructure resources is the focus of this EBD principle. MHS facilities should be designed for flexibility best supported by the concepts of expandability (taking a long-range view) and adaptability (adjusting quickly to immediate needs). The quality of expandability simplifies adding a new service or expanding an existing service. Design concepts to achieve this goal include: Create a circulation network that establishes growth patterns. Place high-tech services (e.g., imaging) on an exterior wall. Vertically stack services that are likely to expand; for critical services, provide a departmental layout with a clear expansion sequence (e.g., linear, cluster, modular). Plan for “plug-in” mobile units; locate major immovable elements so as not to inhibit expansion; size structural systems for vertical expansion (including placement of mechanical units on roofs). Design building systems for ease of expansion. The quality of adaptability could be viewed as a more frequent need to respond to fluctuations in workload, acquisition of new equipment or special events. In this case rooms may simply be re-assigned and/or minor-to-moderate renovation may be required to modify walls, building systems or finishes. Design concepts to increase adaptability include: Using standard modules; ensure that fixed elements (elevators, mechanical/electrical rooms) do not encumber open space. Locating “soft space” where high-tech rooms will be needed; share or swing space with low utilization, adopt design concepts to accommodate potential/expected operational changes (e.g., use a standard private patient room for all acute care beds– medical/surgical, pediatrics, and psychiatry). Using an open space plan with moveable partitions, work spaces and equipment for general office areas, laboratories, and pharmacies; size structural bays to accommodate varying room configurations; design building systems for access and space for additional systems; zone building systems (this allows shut down for repair or to conserve energy without disrupting other areas).

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Using building systems and equipment that can be moved and/or re-configured (mobile partition and shelving units, component headwall systems, etc.). Providing additional fixtures so equipment can be added without construction (additional electrical and communications outlets, stubbed-in plumbing so that an office can become an exam room). Expected patient, staff and resource outcomes associated with achieving the two EBD goals associated with designing for maximum standardization, future flexibility and growth include: Improve patient satisfaction, quality of care, and staff efficiency, as well as all associated costs by using acuity-adaptable rooms to decrease patient transfers. Improve patient satisfaction, quality care and clinical outcomes and staff efficiencies by creating care centers which collocate multidisciplinary care resources for unique patient populations. Reduce resources required to support episodic healthcare missions by ensuring that public spaces are designed to anticipate MASCAL, health fairs, mobilization and other military-unique missions.

Goal 5-1: Reduce Room Transfers
Literature Review Every patient transfer represents an exponential opportunity to introduce error and care delay. With each move, the new care team must be briefed, both verbally and in writing; multiple systems, from the pharmacy to patient administration, must be notified that the patient is in another location; and the patient’s personal effects must be found and moved. A whole new team must learn about the patient and family and the patient and family must develop a new care team relationship. Each hand-off multiplies the inherent patient risks and staff inefficiencies – the “assembly line” model that typifies much of military and civilian care. It certainly does not provide the patient-centered and family-focused care at the heart of EBD. DeFrances, et al (2005) revealed that in 2003, nation-wide, inpatients were transferred from one room to another three to six times over a 4.8 day average length of stay!110 Hendrich and Sorrells (2004) found the turbulence associated with patient transfer and discharge resulted in 40-70% patient daily turnover on a typical nursing unit.111 Unit turbulence rates are a variable tracked by hospitals because of the increased staff effort and consequent staffing impacts. Acuity-adaptable (or “universal”) rooms is an approach designed to mitigate the frequency of patient transfer, by being large enough to accommodate all levels of equipment, furniture and staffing necessary to support intensive through acute care services. The patient stays in the same room and the resources are adjusted around the patient. This is great news for the patient; however, many early adopters have now abandoned this approach because of clinical staff resistance and the challenge of finding staff who can provide intensive- through acute-care services.112

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DoD Space Planning Criteria provides acuity-adaptable rooms as an option. Early planning work for the new NCA facilities engaged the nursing experts, who considered this option. Many of the team held the view that the status quo should remain, which includes the traditional intensive care, step-down and acute medical/surgical units. In general, critical care nurses only want to care for high-acuity patients, and medical/ surgical unit nurses are reluctant to care for this same group. After much discussion, particularly around staffing models and staff training, the decision was made to combine intensive care and step-down care in a single intensive care/intermediate care (ICU/IMCU) room. The nurses reasoned that both ICU and step-down nurses require much of the same training and expertise, so instead of moving the patient to a step-down unit as the patient’s condition improved; they would adjust the amount of staffing. Most RNs and their care team can support 1-2 ICU patients or ~3-4 step-down patients, depending on patient acuity. Schroeder (2007) found one 70-bed, acuity-adaptable, zerotransfer model that abandoned their approach after 12 months because of an inability to find staff cross-trained across the entire spectrum from ICU to medical/surgical acute care. They are now using the model planned for the NCA, where ICU nurses care for the highest acuity patients and patients experience only one transfer to acute services from the ICU. Still, focused transition planning will be necessary to ensure success in the new NCA facilities. Recommended EBD Features and Responses Use Acuity-Adaptable Rooms for Combined ICU/IMCU Care For the most part, this feature is only appropriate for medical centers that care for a large number of patients with high acuity. Future Study Opportunities WRAMC ICU Renovation A renovation project is planned for the existing WRAMC that will incorporate many of the EBD features described, including acuity-adaptable rooms. Patient and staff outcomes should be studied as part of the transition planning for occupying the New WRNMMC and the new Fort Belvoir Community Hospital.

Goal 5-2: Facilitate Care Coordination and Patient Service
Imagine for a moment that you have cancer for which you are now receiving treatment. You report to the cancer care center where the receptionist and nursing care team coordinate your care continuum needs – from providers (primary, specialists, oncologists) to your chemotherapy and radiation therapy teams, all of whom are located in the center: a one-stop experience during probably the sickest time in your life, which demands the most careful coordination of a complex treatment plan. This is the future we envision for those unique, vulnerable patient populations with complex and interrelated healthcare needs. Literature Review Healthcare systems are extremely complex, often characterized by a stunning bureaucracy that serves no customer – neither patient nor staff. The result is patient harm, dissatisfaction and waste. Healthcare leaders know that multiple clinical microsystems

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are what really constitute a healthcare organization. Mohr et al (2004) defines a clinical microsystem as “a group of clinicians and staff working together with a shared clinical purpose to provide care for a population of patients” that shares common core elements: focused type of care, clinicians and staff with the skills and training needed to engage in the required care processes, a defined patient population and a certain level of information and technology to support their work”.113 When John Reiling, President and CEO, led the St. Joseph’s Community Hospital of West Bend, Wisconsin in their replacement facility design that incorporated many EBD features to improve patient safety, he concluded that one of the critical measures of design success was to ensure that the design kept vulnerable populations in mind.114 Nothing in DoD Space Planning Criteria precludes using a care center approach in planning, programming and design. However, it remains critical that representatives from each component of a clinical microsystem collectively envision the care center and the patient services to be provided. This approach was used in the planning for the NCA facilities, made even more complicated by the fact that the NCA will be a regional integrated delivery system, with two locations for many of the care centers. Many hospitals have embraced the hospitality industry’s concierge approach to improve patient satisfaction with services. Designing a central location for patient drop-off or entry combined with staff available to meet and assist patients and their families is an EBD feature that supports this concept. Patient focus groups coordinated by the National Military Family Association as part of the design planning for the new NCA facilities strongly stated their desire to enter at a central location and be greeted by knowledgeable staff, rather than the side and back doors through which they perceive their present entry.115 Hospitals provide critical services during times of national crisis and during mass casualty events. Good hospital design always considers these hopefully rare, but important circumstances. This is particularly necessary in military healthcare, because of the inherent physical risk associated with military missions along the continuum of warfare, including the more routine tasks, such as training warriors. There are many recent events that remind us that the hospital’s physical environment plays a critical role.

Recommended EBD Features and Responses
Optimize Unit Adjacencies with Care Centers Collocating teams who each play a vital role in caring for unique and vulnerable populations creates a patient-focused approach that should also improve staff communication and collaboration. This planning approach was used to program the New Fort Belvoir Community Hospital and WRNMMC projects. Provide Different and Flexible Types of Spaces for Interactive Team Work (See Goal 4-3: Increase Team Effectiveness.) Multiple, flexible spaces allow the care team to interact spontaneously as well as providing space for regular communications.

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Future Study Opportunities Examine Existing Care Centers for Positive Physical Attributes A number of care centers exist in NCA facilities today, such as Breast Cancer Care. A qualitative analysis about the positive and negative physical aspects of these existing centers that engages both staff and patients may provide important information to consider in design and transition planning. Examine the Use of Flexible Public Spaces to Support Multiple Missions, some of which may be Military Unique There has been no systematic review of how the facility design supports multiple care mission requirements, such as MASCALs and the associated patient, staff and resource outcomes, as a consequence. Table top exercises using recent contingency events such as the 9-11 strike on the Pentagon should be simulated with the planned designs for both NCA facilities.

In summary, most of the EBD features that are strongly supported by the literature are being incorporated into the designs for the new military medical facilities within the National Capital Area. DoD Space Criteria have already incorporated the most impactful EBD feature: the use of single-patient bed rooms. Adoption of other EBD features at facilities within the MHS portfolio will require both further studies (specific to the MHS populations) and cultural transformation.

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IV.

EBD Activity Check Lists

Facility Life Cycle Management and Performance Model
The Health Facility Planning Agency subscribes to the Facility Life Cycle Management and Performance Model as a means to achieving their central objective to build reliable facility infrastructure that supports current and future AMEDD missions. The Facility Life Cycle Management and Performance Model dynamically captures the myriad phases associated with any building’s life, as depicted in Figure 2. Typically, its phases include: strategic and business planning, which results in a facilities master plan or portfolio, then specific project planning, programming, design, construction, commissioning, and then building sustainment and retirement. Transition planning represents an additional important activity that spans a number of phases and ensures that all of the steps necessary to move from the present state to the future are identified, planned and successfully executed.
Strategic & Business Planning Sustainment

Facility Master Planning

Commissioning

Transition Planning

Project Planning (New or Renovation)

Construction Design

Programming

Figure 2. EBD can be applied at any stage within the cycle for all kinds of projects.

The Facility Life Cycle Management and Performance Model phases exist for the whole range of facility projects, from Medical MILCON through renovation and life and safety upgrades. Measures of success exist for each phase. Intensive efforts are currently underway to modify the historic linear approach depicted, in order to shorten the existing

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timeline to realize a new facility, primarily through overlapping the work in the planning, programming, design and construction phases. EBD activities exist in every phase of the Facility Life Cycle Management and Performance Model, not just the design phase, as many people think. The focus of this section is to highlight the EBD activities associated with each phase of the model, by first briefly defining each phase and then providing an EBD activity checklist.

Strategic and Business Planning
Strategic Planning Definition Strategic planning represents the long-view, as far as the leadership team can envision— which, in healthcare, is often only five or ten years because of the transforming impacts of technology or healthcare advances. This reality represents a real investment challenge since the MHS typically keeps its buildings for fifty years. Sometimes the strategic plan or opportunity is provided, such as is the case with BRAC- and Army Transformationborn projects. Frequently strategic planning results in the need to update vision and mission statements, which is best achieved by engaging all of the key stakeholders – including patients and their families. The MHS has not consistently engaged its customers across the Facility Life Cycle Model to shape our future facilities in a way that satisfies their pressing concerns and desires. EBD demands a patient-centered and family-focused approach. Most new facility projects are considered because something has changed, such as the served patient population; or the healthcare marketplace or the standards of care delivery have been modified by technology and advances; or new services are needed; or old services require an upgrade. The list is endless, but they all represent change. The other side of the facility coin is that there are issues that need to be resolved, for which the facility can play an important role, as outlined in the previous section of this report. A list of EBD activities associated with strategic planning is provided below. Strategic EBD Questions/Activities Checklist Problems Requiring Resolution What problems are you trying to solve, for which the facility infrastructure may plan an important role? Patient Outcomes such as: reducing hospital acquired infections, patient falls, and medication errors; a lack of patient space to support privacy; improved patient satisfaction; and greater support of family involvement in care. Staff Outcomes, such as decreasing staff injuries and infection and improving staff satisfaction and retention Resource Outcomes such as decreased costs associated with decreased patient lengths of stay and decreased patient use of narcotic medications, improved patient enrollment because of increased satisfaction, decreased sick day salary and compensation costs associated with staff injury, and decreased staff orientation costs associated with reduced staff turnover.

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Are there changes in patient capacity or throughput which are deviant from the norm or that you want to improve? (e.g., length of stay, cost per admission) Are MTF healthcare delivery services fragmented and inefficient today? Will a patient-focused care center approach be used? Cultural transformation, led from the top, underpins every successful EBD experience. Are all of the key stakeholders engaged? Each problem requiring resolution may need a unique team. Are patients and their family members represented in this effort? Does the vision and mission statement reflect the desired future state? Potential Solutions What EBD solutions exist for the identified problems? What clinical and business processes require reengineering? What cultural transformation is necessary? How You Will Measure Success What metrics are used today to measure the problems requiring resolution? Are the metrics adequate to measure success at a national level? What additional metrics are needed? Pay particular attention to the financial quantification of resource improvements. (See Business Planning, below.) Have you identified patient, staff and resource outcome targets that will be realized as a consequence of a comprehensive EBD approach?

Business Planning
Business Planning Definition Business planing reflects the current and strategic state in terms of costs and revenues. The MHS requires all MTFs to use a deliberate Strategic and Business Planning Process, as summarized below. MHS MTF Strategic & Business Planning Process 116 Analyze Market Understand Demand Evaluate Performance Determine Capacity Coordinate HC Delivery Plan Develop Action Plans Assess Financial Impact Submit MTF Plan to OSD/HA Monitor Plan Performance However, while strategic plans look out 5-10 years, the MHS business plans cover only two years, and, as such, provide only limited value to the facility planner. EBD features that represent an initial design or construction cost in excess of current DoD criteria, as well as those EBD features that seemingly cause increased sustainment costs, may require a return on investment analysis (ROI) to demonstrate the ultimate

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savings over the facility life cycle. Readers are strongly encouraged to read Chapter 7, “The Compelling Business Case for Better Buildings” in Improving Healthcare with Better Building Design. The authors use a hypothetical 300-bed project, the so-called Fable Hospital, to demonstrate how to outline first the incremental costs associated with creating a new building and then the financial impact of design decisions.117 Using the Fable Hospital approach, a notional sample of such an ROI associated with the goal of reducing hospital-acquired infections at the New Fort Belvoir Community Hospital is provided below. Return on Investment Analysis – Incremental Costs
EBD Features Single patient rooms – with conveniently placed sinks and dispensers Additional 99.97% HEPA filters in ICU, ER treatment room and one 6-bed med/surg Pod (2 airhandling units) Additional Costs None – current DoD criteria $50,000 $30,000 initial $20,000 annual ops costs Calculations

Initial cost = $15K X 2 = $30K Increased operating cost = $4K/unit/year X2 = $8K Filter replacement = $6K/unit/year X2 = $12K annually Total $50K in the first year

Return on Investment Analysis – Financial Savings Impact
Outcomes Decrease nosocomial infections Savings $100K Calculations 10 fewer infections at ~$10K per patient = $100K

Business EBD Questions/Activities Checklist Has an ROI for desired EBD features been completed to include all incremental costs and a financial impact? This may be an important step even for those EBD features currently included in DoD facility programming, design and construction criteria as a way of estimating the future resource impacts.

Facility Master Planning
Facility Master Planning Definition A Facility Master Plan, sometimes referred to as the facility portfolio, represents the facility capital resource for a healthcare organization and includes: - An inventory of all Category 500 (medical) buildings – or any other buildings used by the medical community; - A facility condition assessment of each building; - Functional assessment of the current space, including the missing but desired EBD features; - Statement of future workload demand and its affect on space needs; - Concept of operations for the missions supported in each of the buildings; - Description of future capital investments specific to mission, scope, cost and schedule, including those new EBD features.

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Facility Master Planning EBD Questions/Activities Checklist What EBD features are lacking in existing healthcare facilities? Inventory current facilities and complete an EBD assessment. What EBD features are included in future projects? Are the right stakeholders involved? Does the EBD ROI require refinement?

Transition Planning
Transition Planning Definition Transition planning underpins all projects—from life safety upgrades to renovation and MILCON projects—by defining the plan for how an organization moves (literally and figuratively) from the current state to the future state. Good transition planning begins the moment a decision is made to pursue a project and continues through post-occupancy evaluation in the sustainment phase. There is an extensive transition planning body of literature, but at a minimum, the step-by-step process to successfully realize all of the needed changes should include: New policies and procedures, staff education and training, equipment and building familiarization, a communications plan, a patient move plan… and much more. Transition Planning EBD Questions/Activities Checklist What is the transformational theme and leadership plan that will frame the communications plan? What EBD features need to be highlighted in transition planing? Who are the key stakeholders to involve in EBD feature transition planning? Are specific resources needed to facilitate EBD future transition planning (e.g., mockup or virtual rooms)? Visit facilities that have used the EBD features planned for your new or modified facility.

Project Planning
Project Planning Definition Project planning represents a detailed concept of operations for each clinical or administrative area, which includes: - Mission statement - Scope of services, training and research - Work volumes - historic compared with future - Staffing - historic compared with future - Key operating assumptions and parameters - Desired adjacencies - Desired layout and workflow - Major equipment Good project planning involves the key, multidisciplinary stakeholders who best understand current operations for each hospital area and, critically, can envision the

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future with regard to their discipline. Surgeon General-appointed consultants provide an additional source of information about future trends and healthcare and administrative practice changes for their areas of expertise that will impact the facility infrastructure. Project planning also considers the project schedule, which is particularly important in retrofit projects that require moving services to a temporary location in order to accomplish the work. Visioning sessions are often a helpful means to clarify the message, image, brand or theme and can be used to identify expected patient, staff and family amenities and to translate those attributes into the built environment. An afternoon visioning session was held for the interior design of the new community hospital at Fort Belvoir on June 8, 2007, preceded by a morning of presentations about EBD. With 70 stakeholders in the room, the architects and designers found the session extremely useful, resulting in a message of “Caring for Our Own” as the theme for the new hospital. Project Planning EBD Checklist Is a visioning session important? What EBD features are included in the project? What is the science that supports each EBD feature? Have these approaches been vetted with TSG consultants? How well does the DoD Space Planning Criteria support the desired EBD features? How do EBD features impact all aspects of the concepts of operation? What clinical or business re-engineering efforts are needed to maximize the facility EBD features? What outcome metrics will be used to measure success?

Programming
Programming Definition Using the DoD Space Planning Criteria Guide as a reference, programming translates the concept of operations into a line-by-line space program document. Because the DoD Space Planning Criteria Guide does not always reflect the latest EBD science, it may be necessary to form a multidisciplinary community of practice to fully address emerging EBD science to mitigate the risk of EBD innovation. The space program document (i.e., Program for Design, or PFD) that is ultimately produced consists of the elements identified below, with full use of the comments section to provide key planning assumption information to the Architect-Engineer. - DoD room code - Room name - Size and number of each type of room - Total NSF - Reference to DoD Space Criteria - Comments Noblis has created, for the planning work in the NCA, a web-based PFD tool which can be used to track the changes in the program for design. Each PFD was vetted with the relevant user groups during the planning and programming phase.

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Programming EBD Checklist How well does the DoD Space Criteria Guide support the desired EBD features? Use the comments section to provide design guidance that links a room to key EBD CONOPS elements.

Design
Design Definition Design involves the creation of drawing plans using a multidisciplinary approach for the builders to use in construction. Designs are submitted in an iterative fashion, which until recently included the following design submittals (“S”): – S1 - Block layout (inpatient, ancillary, outpatient, parking) on the site – S2 - Department adjacencies – S3 - Room adjacencies – S4 - Equipment and furniture layouts within rooms – S5-S6 – the “guts” - communication, HVAC, mechanical, lighting, etc. Intense efforts are underway to transform design and construction practices from a linear, sequential approach to an integrated design-build process, most typically used in the civilian sector, which will reduce the number of designs submitted. Design EBD Activities Checklist At what point in the design plan would you expect to find each of the desired EBD features? During the appropriate design review, ensure that all of the EBD features have been captured. Does the design support the desired EBD future concepts from all perspectives: patient, family and visitors, the community, staff, material movement, equipment use, seamless integration with technology and the digital infrastructure? Has Failure Modes and Effects Analysis been conducted to ensure that the design does not contribute to risks and failure?

Construction
Construction Definition Construction represents the actual building of the facility, including placement of some of the built-in equipment. Historically, construction began after the design was completed. Today, construction may begin as design is being completed, to shorten the time between the decision to build and facility occupancy. Construction EBD Activities Checklist Are the materials Green Guide approved? Are the materials supportive of the desired EBD features? Have precautions been taken to minimize the impact (noise, particles, etc.) of construction on adjacent or nearby facilities and their occupants?

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Commissioning and Occupancy
Commissioning and Occupancy Definitions Commissioning is the process of outfitting the building with the equipment and furniture not included as built-in features during construction. Most equipment must be certified and the materials necessary for care delivery are stocked during this time. Artwork is hung and the final interior finishes are completed. Occupancy represents the act of moving (from the existing facility, if any) to full functional residency in the new facility. Depending on the size of the project, occupancy can occur as one movement or in a phased-approach. Commissioning and Occupancy EBD Activities Checklist Have all of the EBD-required furnishings, equipment and materials been accounted for? Have the final pre-move outcome measures been captured for those variables expected to be impacted by EBD features? Has the community been fully engaged in the final plan to transition to the new EBD facility through the Public Affairs Office, with marketing information about the EBD features and expectations for the new facility? Have the post-occupancy evaluations to evaluate EBD features been planned?

Sustainment
Sustainment Definition Sustainment begins with the post-occupancy EBD evaluations and represents the routine maintenance and repair activities necessary to keep the building in good working order over the life of the building. Sustainment EBD Activities Checklist Have the post-occupancy evaluations of EBD features on patient, staff and resource outcomes been completed at the appropriate times (e.g., at 6, 12, and/or 24 months)? Have the lessons learned been documented and shared broadly? Are there opportunities to insert EBD features with routine maintenance and repair activities, such as: High performance sound-absorbing ceiling tiles? Rubber and carpeted floors where appropriate? Glass that reduces glare? Furnishing replacement and reconfiguration for waiting areas/lounges to provide a residential look? Selection of materials (wall coverings, furniture, etc.) with cleanability and low emissions as key considerations? Improved signage? Housekeeping practices that include frequent cleaning of high-contact surfaces? Well maintained and operated ventilation and water supply systems? Using “green” cleaning materials?

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In summary, EBD activities can occur at every phase of the Facility Life Cycle Management and Performance Model for every type of facility project: regular facility maintenance, life and safety upgrades, renovation and/or renewal projects, and medical MILCON projects.

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V. Summary of Recommendations: A Once-in-a-Lifetime Opportunity
Recommendations
Over the past 10 years, EBD has emerged as a scientific response to the questions about how the built environment impacts patient, staff and resource outcomes. EBD inquiry has exponentially exploded in the wake of the Institute of Medicine’s benchmark studies about the quality and safety of healthcare delivery in America. A review of the existing EBD literature for this report revealed that certain EBD features do in fact improve patient, staff and resource outcomes in the inpatient setting (where almost all of the research has been conducted). The EBD features or responses below are supported by both compelling science and business case and most are already included in AIA and DoD guidelines: Design Single-Bed Rooms with Family Zones – to increase social support, improve patient privacy and confidentiality, improve patient sleep and rest, reduce hospitalacquired infections, decrease patient and family stress and eliminate noisy and chaotic environments. Provide HEPA Filtration – at 99.97% to reduce airborne-transmitted hospitalacquired infections. Install Ceiling-Mounted Patient Lifts – to reduce patient falls and decrease staff back pain and work-related injuries. Use Sound-Absorbing Materials, Especially High-Performance SoundAbsorbing Ceiling Tiles – to improve privacy and confidentiality, improve patient sleep and rest, reduce noise stress and improve speech intelligibility, and eliminate noisy and chaotic environments. Design Walled Rooms for Admitting, Examination and Treatment Spaces, rather than open-plan rooms with curtains that divide separate patient spaces – to improve patient privacy and confidentiality, provide adequate and appropriate light exposure, improve patient sleep and rest, reduce noise stress and improve speech intelligibility, decrease patient and family stress, and eliminate noisy and chaotic environments. Maximize Natural Light throughout the Building – to improve patient rest and sleep, decrease patient and family stress, and reduce staff fatigue. Reduce or Eliminate Loud Noises – to improve patient sleep and rest, reduce noise stress and improve speech intelligibility, and eliminate noisy and chaotic environments. In addition, the literature and best practices research identified a host of recommended EBD features and responses that represent both good design choices and good facility management practices. Many do not require additional front-end investments. These features, with good supporting evidence in the literature, are: Residential-feeling, as opposed to institutional, waiting areas Acuity-adaptable rooms for a combined intensive and intermediate care unit
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Patient controls of light, glare and temperature Improved lighting levels in areas where medications are prepared and dispensed and in procedure areas Windows in staff break rooms Convenient food facilities for patients and families Decentralized inpatient nursing support Regular maintenance, cleaning and inspection of water systems (or use of looped water systems to minimize maintenance requirements) Proper water treatment practices Avoiding decorative water fountains in high-risk patient care areas Cleaning high-contact surfaces frequently Sinks and hand-washing dispensers Ensuring that HVAC systems are well maintained and operated Materials and furnishings that do not emit toxins Isolate construction and renovation areas from patient-care areas Provide secure access to nature Provide positive distractions (music, appropriate art, etc.) Provide multiple spiritual spaces and haven areas Use softer floor materials like carpet and rubber as appropriate Ergonomically evaluate work areas Decentralize staff support spaces (e.g., supplies and charting areas) Provide flexible spaces for interactive team work Consider using brass or copper door handles Optimize unit adjacencies with Care Centers, (e.g., Cancer Care, Musculoskeletal Care). As was demonstrated in the previous section, EBD activities exist in every phase of the Facility Life Cycle Management and Performance Model, not just the design phase, and are provided as a checklist for use by the facilities community.

Next Steps
Much MHS work is needed to institutionalize EBD research and findings. Successful institutionalization includes all of the following activities: Engage Senior Leaders. Senior leaders must be engaged and EBD champions identified to provide the transformational leadership essential to EBD success. Partner with Clinical and Administrative Peers. The built environment is one of many tools used to provide quality patient care and a positive workplace. All EBD work should be accomplished in deliberate partnership with the clinicians and administrators who can then lead the necessary clinical and business-process engineering necessary to maximize these expensive facility investments. Include Patients and Their Families in Health Facility Planning Activities. Our customers must be involved in all aspects of their care.

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Review and Update Policy. Do the current DoD facility policies and guidelines include all of the recommended EBD features and responses? A standard Return On Investment analysis process for EBD projects should be drafted and completed with the resource managers. Review and Restructure Health Facility Organizations. Are the Service (e.g., Army Health Facility Planning Agency, MEDCOM ACS for Installations and Environment) and OSD/HA-TMA facility organizations structured to incorporate and monitor EBD activities across the spectrum of facility responsibilities—from Medical MILCON projects to Life and Safety upgrades—and to partner with key clinical and administrative policy peers? How will the organizations support inquiries for known and emerging EBD information? Develop Processes to Harvest Emerging EBD Findings. As EBD research efforts continue to grow in both the public and private sectors, there is a need to establish processes to harvest and share emerging EBD findings. Many health facility staff attend national meetings and conferences, but seem to have difficulty translating what is learned into a practical resource that informs their work. Evaluate EBD Cost-Estimating Guidance. Many EBD features and responses are consequent to good design with existing criteria. Current EBD costing-estimate guidance should be evaluated, with particular attention paid to grossing factors associated with EBD facilities. Current preliminary results of a study at Clemson & Texas A&M shows contemporary grossing factors do not differ significantly from those of some time ago.118 Perform Return on Investment Analysis. For many recommended EBD features, there will be an associated capital cost. While the EBD literature suggests that return on investment is possible within relatively short periods of time for many of these features, so many factors influence the determination of both cost and potential savings that it is difficult to make an overarching statement that incorporation of EBD features will definitely save the MHS money. For each building project, the planning and programming teams should take the time to perform ROI analyses of the features that they have determined to be most desirable for their project. This will necessitate the development of agreed upon outcome measures, defined in a way to afford the greatest ability to compare findings with those in the civilian sector and across the MHS. Disseminate EBD Information. How will each Service and OSD/HA-TMA disseminate EBD information? What basic EBD education experiences are needed? How can the training be accomplished using existing forums as well as other means (e.g., web symposium) to provide the widest dissemination of information? Presentations should be provided at major clinical and administrative forums, not just those forums that traditionally support the facilities community. Review Outcome Metrics Definitions and Methodology. Are the outcome metrics used to measure success commensurate with those used in the civilian sector? Coordination with the DoD Metrics Standardization Board may be necessary.

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Conduct EBD Research in the Ambulatory and Dental Environments. Almost all of the EBD research has occurred in the inpatient environment. Many EBD features found to improve patient, staff and resource outcomes in the inpatient environment would seem to be transferable to the outpatient and dental environments, which represent the largest portion of the DoD facilities portfolio. Become a Pebble Project. The MHS has a unique opportunity to become an active member in the national community to further EBD by becoming a member of the Center for Health Design’s Pebble Project (see page 14 for more information about the project). At a minimum, the New Fort Belvoir Community Hospital, the New Walter Reed National Military Medical Center, and the New San Antonio Military Medical Center should be Pebble Projects. Refine the Post-Occupancy Evaluation Process. Post-Occupancy evaluations now need to include an analysis of patient, staff and resource outcomes impacted by the facility project. Redefine the Life Cycle Cost Analysis. Current healthcare facility life cycle cost analysis is based on a traditional, nonhealthcare facility approach and ignores the heart of our business: providing patientcentered and family-focused care. The life cycle cost analysis should be broadened to include the financial impacts associated with improving patient, staff and resource outcomes compared to the facility investments proven to improve those outcomes. Publish MHS EBD Experiences and Lessons Learned. The MHS frequently leads the way in innovation, but rarely or inadequately shares those innovations and outcomes in a formal way. Formalize Current EBD Working Groups. The Epidaurus Project and the EBD Working Group should be formalized under TMA as an Integrated Process Team (IPT) to facilitate many of the next steps described here. Conclusion With a $6 billion portfolio of new healthcare facilities and projects planned over the next five years119, the MHS finds itself with a once-in-a-lifetime opportunity to transform the healthcare infrastructure to improve patient, staff and resource outcomes and to contribute to the body of EBD science. This report provides a snapshot of the current EBD evidence applied to MHS EBD goals and principles that can be used to transform and educate the MHS healthcare community. Although the current AIA and DoD planning criteria embrace many of the recommended EBD features, the reader is encouraged to stay abreast of the latest EBD information through the Center for Health Design and is reminded that maximizing EBD investments depends on transformational leadership and clinical and business process reengineering. Employing recommended EBD features and responses across the Facility Life Cycle provides a singular opportunity to create the next generation of MHS healthcare facilities that can support the outcomes our warriors and their families deserve.

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ATTACHMENTS

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Case Studies: Facility Tours
During this study, team members attended four EBD-related conferences (see “Methodology” in the Introduction section of this report). Hospital facility tours were offered at two of these conferences (The Center for Health Design conference in Chicago and the ASHE conference in San Antonio). Team members toured two facilities: Provena Mercy Medical Center and the Spine Hospital of South Texas. Provena Mercy Medical Center The Provena Mercy Medical Center, located in the Chicago-suburb of Aurora, IL, is an award-winning, 365-bed hospital. The medical center sees over 12,000 inpatients (only 12% are births) and 170,000 outpatients per year. Their clinical focus is on heart and vascular health as well as on surgery, diabetic wellness, and intensive care. As part of their five-year campus master plan, they opened a new Outpatient and Surgery Center (100,000 SF dedicated to both inpatient and outpatient surgery) in 2005, and a new 16bed ICU in 2006. Both areas were included in the facility tour. Design, construction and occupancy of the new ambulatory care center focused on improving the patient and family experience, and concurrently attempted to update their brand recognition. Design features included at Provena included an overall nature theme, using a lot of natural wood and a leaf motif; living-room-like waiting and reception areas; softer floors in the state-of-the-art operating rooms, which were linked via camera to a nearby classroom to increase opportunities for education while minimizing both the chance of infection and the overall floor space required in the OR; all OR equipment was on booms from the ceiling, allowing the room to be configured in whatever way the surgeon is most comfortable, and the nurse’s charting area is located to maintain visual contact with the patient while entering information into the computer. Even the mechanics of the building were constructed with the intent of safety and efficiency. There is a control room where monitors show the status of various systems (water, heat, cooling, air exchanges, etc.) throughout the building. The patient rooms are all single-bed, with windows to outside, and the toilet area is hidden behind a ¾ height wall, with no door and a wide entry area in the hopes of minimizing patient falls. Each room has a sink as well as alcohol-based cleaning dispensers. Each bed is visible from the central nursing station. In the Recovery area, windows have been added to allow natural light in. The vice president in charge of the facility project stressed that process re-engineering and cultural transformation are as important as facility design. He said that he reminded every staff member that the new space makes them “new” employees, with new process flows and behavioral patterns to establish. Form does dictate function. Provena Mercy Medical Center is the 2007 recipient of the Cardiac Surgery Excellence Award (from HealthGrades). They are rated in the top 10% of hospitals nationally for cardiac surgery.

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The Spine Hospital of South Texas The Spine Hospital of South Texas is a fully licensed, acute care hospital, specializing in orthopedics and diagnostic imaging. It was built in 2002 and has approximately 45,000 square feet of space, 6 operating theaters, 2 treatment rooms and 30 patient rooms. The hospital is a for-profit, privately-owned, physician partnership attached to a private medial office building (where the majority of ambulatory visits and minor procedures are performed). The physician owners and their partners designed and built the facility with a focus on efficiency, patient care and safety, and patient satisfaction. The single floor layout of this small hospital provides staff efficiencies in monitoring the flow of patients (e.g., dual coverage of a small emergency department and inpatient units with low patient census on weekends) with efficient staffing ratios. Also, design elements for the productive spaces such as the operating rooms include separate circulation of patients versus staff and equipment. This facility design results in maximizing the use of space while enhancing patient safety and satisfaction. The Hospital has consistently received high patient satisfaction scores and was named Best in Customer Service (July 2004) by National Surgical Hospitals. The staff are welltrained to be sensitive to the patient needs, including family-centered care. The focus on a warm and caring environment is reinforced by the design of “hotel-like” amenities, including larger patient rooms, large tiled showers in private toilet rooms, carpeted hallways, and warm interior colors and design features.

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Case Study: Applying EBD in the National Capital Area

Attachment 2

Case Study: NCA/BRAC MILCON - Applying EBD Principles
EBD Principles were applied to the BRAC MILCON projects in the National Capital Area during the Programming phase. The principles used are listed below, along with the EBD features that have been included in the programs for design. Both projects (the new Walter Reed National Military Medical Center at Bethesda and the new community hospital at Fort Belvoir) are in the active design phase at this time. Given the nature of the facility life cycle, it is possible that things will change between now and occupancy; however, the features identified below are currently expected to be incorporated into the final construction projects. These are the first major MILCON projects in the MHS to incorporate EBD, and as such, represent a “living laboratory” for the application of EBD in the MHS.

EBD Design Principles used in Epidaurus
Create a patient- and family-centered environment that respects privacy and dignity and relieves suffering. Improve the quality and safety of healthcare delivery. Create a positive work environment through ergonomics, efficiencies, lighting and adjacencies. Design for maximum standardization, future flexibility and growth. Support care of the whole person, enhanced by contact with nature and positive distractions.

Single-Bed Inpatient Rooms
New standards: 2006 AIA Guidelines and DOD Space Planning Criteria At New Community Hospital, Ft. Belvoir: All single-bed rooms, except for behavioral health who requested semi-private rooms as part of the therapeutic milieu At Walter Reed National Military Medical Center, Bethesda: – 9% Medical/Surgical beds (170 total) – 43% Hematology/Oncology beds (24 total) – 100% Executive Medicine beds (6 total) – 100% ICU/IMCU beds (50 total) – acuity adaptable beds to decrease patient transfers – 100% Mother Infant Care Unit – Couplet Care (24 beds) – 0% Behavioral Health – semi-private rooms requested

Patient and Staff Support on Inpatient Units
Pod-design with Decentralized Support Keep the nursing staff close to the patient to improve patient safety and quality of care and to decrease staff fatigue and stress. – Nurses station to support charting and computer access, which keeps the nursing staff closer to the patient – Clean supplies and automated medication dispensing for routine drug therapy

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– Soiled material collection – Linen supplies Electronic medical record access - We envision a wireless environment. Room Service Concept - Patients can order what they want to eat when they want it. Staff work space - Hoteling space for clinicians and administration staff

Other Patient-Centered Concepts Adopted
Large inpatient rooms Provide social support and engage the family in care delivery. – Family space – Staff space Private prep and recovery spaces in treatment areas Patient/family education kiosks and conference rooms in clinics Clinical care centers: – Cancer – Musculoskeletal – Children’s Health – Women’s health Functional placement of services to reduce patient travel

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Attachment 3

Memo from Dr. Winkenwerder

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Future Study Opportunities
Throughout the body of the EBD Study final report, suggestions have been listed about opportunities for future study. If the MHS participates in the Center for Health Design Pebble Project, these recommendations might serve as a starting point. Researching the following issues within the MHS—and applying the findings to both the operations and facilities of MTFs—may ultimately help to improve healthcare delivery, satisfaction and outcomes.

EBD Principle 1: Create a Patient- and Family-Centered Environment
Goal 1-1: Increase Social Support Active Duty Roommates The presence of a roommate has been found to be more stressful than restorative, primarily because of noise and loss of privacy. However, the “buddy” approach pervades military culture from training base to battlefield. Do active duty patients experience the same sort of stress when they have an active duty roommate as is seen in the civilian population experience? Behavioral Health Roommates Unlike other inpatient specialty units, behavioral health staff requested semi-private rooms to further the therapeutic milieu approach in the BRAC NCA projects. Civilian inpatient behavioral health facilities also seem to be moving towards private rooms. What are the benefits and consequences for patient, staff and resources with either choice? Goal 1-2: Reduce Spatial Disorientation MHS Wayfinding Stress Conduct studies to ascertain the magnitude of MHS patient and visitor stress associated with poor wayfinding and consequent spatial disorientation. A first step might be a question about satisfaction with ease of wayfinding on MHS patient satisfaction surveys. A sub-component study might focus on the tertiary medical centers to which combat casualties are evacuated and to which their families arrive during a uniquely stressful time. Goal 1-3: Improve Patient Privacy and Confidentiality MHS Patient Satisfaction with Privacy Identify current patient satisfaction with regard to privacy and identify those physical attributes that contribute both positively and negatively. Evaluate Speech Privacy in MHS Open-Rooms, With Multiple Beds or Chairs DoD Space criteria continues to support open rooms, with multiple beds and chairs for a number of care areas, such as the post anesthesia care unit and primary care treatment rooms. Speech privacy should be evaluated and the criteria modified, as appropriate.

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Goal 1-4: Provide Adequate and Appropriate Light Exposure Impact of Different Lighting Conditions on Staff Work Performance Providing quality healthcare involves multiple complex tasks from medication preparation and administration, conducting invasive and non-invasive procedures, and documenting care. Several studies summarized in Joseph’s 2006 article on light showed that exposure to intermittent bright light during the night shift is effective in adapting circadian rhythms of night-shift workers.v Additional research is needed to understand the ideal light level for a variety of error-prone tasks by workers of varying ages. Impact of Natural Light versus Artificial Light on Staff Mood and Performance Some studies have shown that staff exposure to natural light has a positive impact on their work experience. More work is needed to understand the importance of natural light to staff and specifically any impacts on staff performance, especially as the healthcare workforce ages. Goal 1-5: Support Optimal Patient Nutrition Assess Current MHS Food Service Facilities and Family Involvement with Nutrition A nutrition support question might be included on the MHS patient satisfaction survey as a first step to understanding the current status of this issue. Simultaneously, a community of practice involving patients, their family members, nutritionists, nursing staff and providers could be formed to: Explore the degree to which a problem exists, particularly for war-wounded patients who experience lengthy hospitalizations far from home. Identify potential improvements that require a facility solution and the associated costs of such solutions. Identify patient outcome improvements and quantify these. Identify family nutrition support requirements. Conduct a return on investment (ROI) analysis to request approval and funding for additional building features. Goal 1-6: Improve Patient Sleep and Rest Patient Satisfaction with Sleep and Rest Current patient satisfaction with the quality of rest and sleep in MHS facilities is unknown. Inpatient satisfaction surveys could be modified to include a question about this important patient outcome. Depending on the results, a community of practice may need to be formed to address identified problems and to consider facility solutions and clinical practice modifications. Goal 1-7: Decrease Exposure to Harmful Chemicals Green Guide Adherence Across Each Phase of the Facility Life Cycle Performance and Management Model The degree to which the Green Guide recommendations are adhered to at each phase of the Facility Life Cycle Management and Performance Model, but particularly in the sustainment phase is not known.
v

Joseph, A. August 2006. “Impacts of Light on Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org,

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EBD Principle 2: Improve the Quality and Safety of Healthcare
Goal 2-1: Reduce Airborne Transmitted Infections Reduce MHS Airborne HAI Infections Currently, HEPA filtration is routinely planned for specialty MHS operating rooms and positive pressure rooms. Recommend that a community of practice -- consisting of infectious disease and infection control clinicians, patient safety and performance improvement staff, along with healthcare facility experts be established to: Determine if airborne nosocomial infections are a problem and if so, what patient population is at risk. Identify additional locations where HEPA filtration should be added to potentially improve patient outcomes. Target specific outcome improvements and quantify savings. Conduct a return on investment analysis to request approval and funding to add additional HEPA filters, as appropriate. HEPA Efficacy in Asymmetric Warfare: Biological Agents The military has a unique role during contingency operations. Recent employment of asymmetric warfare techniques increases the potential for use of other technologies, such as dirty bombs with biological agents. Study is needed to understand the role hospital HEPA environments might play in successfully responding to such contingencies. Evaluate Ventilation Exchange Requirements for Severely Immunocompromised Patients Examine the current criteria for ventilation, particularly for severely immunocompromised patients, in the form of air exchange rates as a second variable, using the same study process described for HEPA filtration. Use of UV to Mitigate Airborne-Transmitted Viruses The military has particular interest in understanding any positive role that UV technology might play with regard to reducing the number of airborne transmitted viruses. In the past, basic training environments have been plagued by varicella and influenza outbreaks, and world-wide missions make warriors vulnerable to SARS and other viruses. Infected warriors may require hospitalization, which further enhances a need to understand the role UV plays in mitigating airborne transmitted viruses in MHS facilities. Goal 2-2: Reduce Infections Spread Through Contact The Ideal Location for Sinks and Hand Washing Dispensers It is not clear how many sinks or alcohol-based hand-cleaner dispensers are needed, nor the ideal location of these devices to positively contribute to improved staff compliance with hand washing. The MHS could develop such a study as a component of an MHSwide initiative to reduce HAI to identify the preferred location for alcohol-based hand cleaner dispensers to stimulate staff compliance. Use of Copper Alloys for High-Touch Surfaces The germicidal properties of copper (and its alloys, such as brass) have long been known, and the effect on Methicillin-resistant staphylococcus aureus and other infectious

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bacteria (including E. coli) has been studied in the laboratory. However, only limited studies have been done in the healthcare environment. The MHS could study the effect of using these materials for high-contact surfaces in areas where patients are particularly vulnerable to infection, such as the ICU or ER. Goal 2-3: Prevent Waterborne Infections (None.) Goal 2-4: Reduce Medication Errors Optimal Lighting Requirements for Medication Administration Activities More research is needed to understand the optimal lighting requirements for supporting medication administration and staff performance. Impact of Family Presence on Medication Errors The impact of family member presence on medication errors for those patients cared for in single-bed rooms with family support space versus those patients cared for in multibed rooms without family support space is worth studying. Impact of Decentralized Nursing Support on Medication Errors Decentralized nursing support is planned for the New WRNMMC and Fort Belvoir Community hospitals, to include automated medication dispensing for routine and scheduled medications. It is not known what impact this will have on medication error rates. Goal 2-5: Prevent Patient Falls Reduce Patient Falls in MHS Hospitals Patient falls are also a problem in MHS hospitals. With the Patient Safety and Performance Improvement communities, the impact of recommended EBD features in new MHS hospitals combined with other fall prevention initiatives should be studied with regard to reducing the number of patient falls. Impact of Decentralized Support on Patient Falls The impact of decentralized support on the incidence of patient falls in MHS hospitals is not known. Perhaps a present unit could be configured with the decentralized support described and then evaluated with regard to patient falls and other key safety and quality patient outcomes as part of the transition planning activities for the NCA projects. An ICU unit under renovation in the current WRAMC will include decentralized support and could be used for this study. Goal 2-6: Reduce Noise Stress and Improve Speech Intelligibility Evaluate the Practice of Replacing Existing Ceiling Tile with High-Performance Sound Absorbing Acoustical Ceiling Tile and Its Impact on Patient Outcomes Select any current inpatient unit with old ceiling tile and replace it with the recommended tile and evaluate patient rest, sleep, satisfaction, perception of pain and need for medication before and after replacement.

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EBD Principle 3: Enhance Care of the Whole Person (Contact with Nature & Positive Distractions)
Goal 3-1: Decrease Patient and Family Stress MHS Patient Satisfaction with Access to Nature Positive Distractions Identify current patient satisfaction with regard to access to nature and positive distractions and identify those elements that positively and negatively contribute to the care of the whole person.

EBD Principle 4: Create a Positive Work Environment
Goal 4-1: Decrease Back Pain and Work-related Injuries Reduce Patient and Staff Injury Incidence and Severity Inclusion of the above-recommended EBD features represents just one element of a comprehensive MHS Zero-Lift policy. Such a program should be developed and then studied with regard to the costs of mitigating injuries contrasted with negative patient outcomes to include injury and associated increased care costs and litigation, as well as injured staff costs associated with medical care, compensation, sick days, restricted duties, and retention. Ergonomic Evaluation of Work Areas There are many healthcare environment areas that require further ergonomic evaluation and study to understand what features in the built environment will reduce staff injury. Needle Stick Injuries Needle sticks are another common staff injury, which universally require medical evaluation and very often, prophylactic treatment to avoid potential life-threatening consequences. The physical environment may play an important role, specifically as it relates to the location and use of sharps disposal boxes within a standardized room configuration. Goal 4-2: Reduce Staff Fatigue Decentralized Staff Support Planned for The New Community Hospital at Ft. Belvoir. Decentralized staff support is planned for the New Community Hospital at Fort Belvoir and some units at the New Walter Reed National Military Medical Center at Bethesda. The decentralized support includes: charting, clean supplies and clean linen, soiled collection and automated medication dispensing for routinely scheduled medications. Efforts should be made to understand the impacts of this investment on patient and staff outcomes, to include staff fatigue. In addition, there may be increased pharmacy and logistic staff costs associated with packaging and distributing medications and materials to more locations on each unit. Goal 4-3: Increase Team Effectiveness Provider and Patient Satisfaction Using a Care Center Approach Both NCA projects provide an opportunity to study changes in provider and patient satisfaction and errors using a care center approach. A number of care centers exist today

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at WRAMC and NNMC and could be studied with regard to team effectiveness and patient satisfaction. Smaller Unit Size to Foster Interaction DoD Space Criteria provides specific recommendations for the number of beds by specific unit type. At the New WRNMMC, a number of the planned medical surgical units are larger than the DoD recommendation not to exceed 36 beds because of funding and physical constraints. A pod design concept with decentralized support was planned to mitigate some of the challenges inherent in large units. Likewise, many civilian hospitals also are building large units (40 beds) with pod support. Understanding and applying civilian lessons learned about team effectiveness with regard to this approach is an important transition planning undertaking. Goal 4-4: Eliminate Noisy, Chaotic Environments NCA MTF Noise and Impact on Staff Stress, Performance and Retention. There is little baseline information about the impacts of existing NCA stressful environments, like the ICUs, on staff. Replicating Topf and Dillon’s study may provide important insights for the new facilities, particularly with regard to staff training and developing policies and guidelines.

EBD Principle 5: Design for Maximum Standardization, Future Flexibility and Growth
Goal 5-1: Reduce Room Transfers WRAMC ICU Renovation A renovation project is planned for the existing WRAMC that will incorporate may of the EBD features described, including acuity adaptable rooms. Patient and staff outcomes should be studied as part of the transition planning for occupying the New WRNMMC and Fort Belvoir Community Hospital. Goal 5-2: Facilitate Care Coordination and Patient Service Examine Existing Care Centers for Positive Physical Attributes A number of care centers exist in NCA facilities today, such as Breast Cancer Care. A qualitative analysis about the positive and negative physical aspects of these existing centers that engages both staff and patients may provide important information to consider in design and transition planning. Examine the Use of Flexible Public Spaces to Support Multiple Missions, Some of Which May Be Military Unique. There has been no systematic review of how the facility design supports multiple care mission requirements, such as MASCALs and the associated patient, staff and resource outcomes, as a consequence. Table top exercises using recent contingency events such as the 9-11 strike on the Pentagon should be simulated with the planned designs for both NCA facilities.

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End Notes

END NOTES

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End Notes

END NOTES
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"The Four Levels of Evidence-Based Design Practice. “ D. Kirk Hamilton, Healthcare Design, November 2003. From the abstract of “Crossing the Quality Chasm”, March 2001, by the Institute of Medicine (part of the National Academy of Sciences). “Building a Health Care System That Works: Here, There and Everywhere.” Institute for Healthcare Improvement, December 2006. 2006 Guidelines for Design and Construction of Health Care Facilities. 2006. The Facility Guidelines Institute, the American Institute of Architects Academy of Architecture for Health. Chapter 1.2: Environment of Care, pp 15-20. Planetree website. http://www.planetree.org/about/welcome.htm Suggested by Mr. Don McKahan, AIA, FACHA (Health Facility Planner); ([email protected]) and Mr. Joseph Strauss, AIA, Architect at Noblis. Suggested by Dr. Anjali Joseph, Director of Research, The Center for Health Design. Military Health System. “Quadrennial Defense Review: Roadmap for Medical Transformation.” 3 April 2006. Ulrich, R., Zimring, C., Quan, W., and Joseph, A. 2004. “The Role of the Physical Environment in the Hospital of the 21st Century.” Concord, CA: The Center for Health Design, web site, www.healthdesign.org, in the Research Reports section. Ulrich, R., and Joseph, A. November 2005. “Scorecards for Evidence-Based Design.” Concord, CA: The Center for Health Design, web site: www.healthdesign.org Joseph, A. 2007. Personal communication 3 May 2007. Nelson, C, West, T., Goodman, C. 2005. “The Hospital Built Environment: What Role Might Funders of Health Services Research Play?” Rockville, MD: Agency for Healthcare Research and Quality, Publication Number 05-0106-EF. Marberry, S.O. Ed. 2006. Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press Schroder, K. 2006 “Designing for Quality: Potential for Facility Design to Elevate Patient Outcomes.” 2007Innovations Center: Health Care Advisory Board, p.11 Joseph, A and Ulrich, R.S. January 2007. “Sound Control for Improved Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Joseph, A. 2006. “The Impact of the Environment on Infection in Healthcare Facilities.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Joseph, A. August 2006. “Impacts of Light on Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Joseph, A. 2006. “The Role of the Physical and Social Environment in Promoting Health, Safety and Effectiveness in the Healthcare Workplace.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Zimring, C. 2007. Personal communication with the author of the soon-to-be published article. Roberts, G. and Guenther, R. 2006. In Chapter 5 “Environmentally Responsible Hospitals.” in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, pp. 81-107.

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See www.gghc.org ; Green Guide for Health Care version 2.1. and www.usgbc.org; Leadership in Energy and Environmental Design (LEED) Green Building Rating System. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environment’s Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 53. Uchino, B.N. and Garvey, T.S. 1997. “The Availability of Social Support Reduces Cardiovascular Reactivity to Acute Psychological Stress.” Journal of Behavioral Medicine 20(1):15-27. Holahan, C.J. 1972. “Seating Patterns and Patient Behavior in an Experimental Dayroom.” Journal of Abnormal Psychology 80 (2): 115-124. Melin, L., and Gotestam, K.G. 1981. “The effects of Rearranging Ward Routines on Communication and Eating Behaviors of Psychogeriatric Patients.” Journal of Applied Behavior Analysis 14 (1): 47-51. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environment’s Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 54. Sallstrom, C., Sandman, P.O. and Norber, A. 1987. “Relatives’ Experience of the Terminal Care of Long Term Geriatric Patients in Open Plan Rooms.” Scandinavian Journal of Caring Science 1 (4): 133-40 Personal communication with Sheila Bosch, Georgia Tech University, 27 June 2007. Landro, L. 12 July 2007. “ICUs’ New Message: Welcome Families." The Wall Street Journal, Section A1 and 12. Zimring, C. 1990. “The Costs of Confusion: Non-Monetary and Monetary Costs of the Emory University Hospital Wayfinding System.” Atlanta: Georgia Institute of Technology Presentation at the MHS TRICARE Conference, January 2007. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environment’s Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 42-45. Malkin. J. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 113-114. Ibid. Boodman, S. G. “A Silent Epidemic.” The Washington Post, February 20, 2007, F1-F2. Barlas, D., Sama, A.E., Ward, M.F., and Lesser, M.L. (2001). “Comparison of the Auditory and Visual Privacy of Emergency Treatment Areas with Curtains Versus Those with Solid Walls.” Annals of Emergency Medicine 38 (2), 135-139. Joseph, A and Ulrich, R.S. January 2007. “Sound Control for Improved Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, pp 6-9. Ibid, p7. Joseph, A. August 2006. “Impacts of Light on Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.4-8. Ibid, page 5. Walch, J. M., Rabin, B. S., Day, R., Williams, J. N., Choi, K. and Kang, J. D. (2005) “The Effect of Sunlight on Postoperative Analgesic Medication Usage: A Prospective Study of Spinal Injury Patients.” Psychosomatic Medicine 67(10, 156-163. Joseph, A. August 2006. “Impacts of Light on Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.3-4.

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Buchanan, T.L., Barker, K.N., Gibson, J. T., Jiang, B.C., and Pearson, R.E. (1991). “Illumination and Errors in Dispensing.” American Journal of Hospital Pharmacy 48 (10), 2137-2145. Joseph, A and Ulrich, R.S. January 2007. “Sound Control for Improved Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p. 5. www.gghc.org; Green Guide for Health Care version 2.1. Nycz-Xonner, J. 2007 “Scrub In: Infections Take Fiscal, Human Toll, Force Hospitals to Clean Up.” Washington Business Journal, March 26, 2007, http://washington.bizjournals.com/washington/stories/2007/03/26/focus1.html Pennsylvania Health Care Cost Containment Council. 2006. “Hospital Acquired Infections in Pennsylvania.” www.phc4.org , p.1. Spinner, J. 2007. “Resilient Infections Worry Military Doctors.” The Washington Post, 5 May 2007, pp. B1-2. Joseph, A. The Impact of the Environment on Infection in Healthcare Facilities. .” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.1-6. Sherertz, R. A., Belani, A., Dramer, B.S., Elfenbein, G. J., Weiner, R. S., Sullivan, M. L. et al. (1987) “Impact of Air Filtration on Nosocomial Aspergillus Infections: Unique Risk of Bone Marrow Transplant Recipients.” American Journal of Medicine, 83 (4), 709-718. Hahn, T, Cummings, K. M., Kichalek, A. M., Lipman, B. J., Segal, B. H., McCarthy, P. L. 2002. “Efficacy of High-Efficiency Particulate Air Filtration in Preventing Aspergillosis in Immunocompromised Patients with Hematologic Malignancies.” Infection Control and Hospital Epidemiology 23 (9), 525-531. Passweg, J. R., Rowlings, P. A., Atkinson, K. A., Barrett, A. J., Gale, R. P., Gratwhohl, A., et al. 1998. “Influence of Protective Isolation on Outcome of Allogeneic Bone Marrow Transplantation for Leukemia.” Bone Marrow Transplant 21 (12), 1231-1238. Noskin, et al. (2001) “Engineering Infection Control through Facility Design. Emerging Infectious Diseases, 7 (2), p ____. Menzies, D., Popa, J., Hanley, J.A., Rand, T., and Milton, D. K. 2003. “Effect of Ultraviolet Germicidal Lights Installed in Office Ventilation Systems on Workers’ Health and Wellbeing: Double-Blind Multiple Crossover Trial.” 362 November 29, 2003, pp. 1785-1790. Escombe, A. R., Oeser, C. C., Gilman, R. H., Naavincopa, M., Pan, E. W., Martinez, C., et al. 2007 “Natural Ventilation for the Prevention of Airborne Contagion.” Public Library Science of Medicine, found at http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040068 Joseph, A. The Impact of the Environment on Infection in Healthcare Facilities. .” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.5. Ibid, p. 6. Collins, B.J. 1988 “The Hospital Environment: How Clean Should a Hospital Be?” Journal of Hospital Infection Control, 17 (6), 330-339. “Oligodynamic effect” reference in Wikipedia.com. Original article by Nägeli: v. Nägeli K.W. 1893. Über oligodynamische Erscheinungen in lebenden Zellen. Neue Denkschr. Allgemein. Schweiz. Gesellsch. Ges. Naturweiss. Bd XXXIII Abt 1. Michels, H.T.; Wilks, S.A.; Noyce, J.O.; and Keevil, C.W. 2005. “Copper Alloys for Human Infectious Disease Control.” p. 1-11. Download at: www.cda.org.uk/antimicrobial/downloads/infectious_disease.pdf Joseph, A. “The Impact of the Environment on Infection in Healthcare Facilities.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.11-12.

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Rogers, J. 2006. The Debate over Decorative Fountains in Healthcare Environments: How Great is the Infection Control Risk?” Research Design Connections, Winter 1-3. Ulrich, R., Zimring, C., Quan, W., and Joseph, A. 2004. “The Role of the Physical Environment in the Hospital of the 21st Century.” Concord, CA: The Center for Health Design, web site, www.healthdesign.org, in the Research Reports section, p.12 Institute of Medicine. 2007. Preventing Medication Errors: Quality Chasm Series. Washington D.C.: National Academies Press, Appendix D. p.413. Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., Roth, E. A., and Shekelle, P. G. 2004. “Interventions for the Prevention of Falls in Older Adults: Systematic Review and Meta-Analysis of Randomised Clinical Trials.” British Medical Journal. 328 (7441): 680. Brandis, S. 1999. “A Collaborative Occupational Therapy and Nursing Approach to Falls Prevention in Hospital Patients.” Journal of Quality in Clinical Practice. 19 (4), 215-21. Walker, Dalton. “Hospital in Bronx Shows How to Turn Volume Down.” July 6, 2007. The New York Times. Busch-Vishnia, I., West, J., Barnhill, C., Hunter, T., Orellana, D., and Chivukula, R. 2005 “Noise Levels in Johns Hopkins Hospital.” Journal of the Acoustical Society of America. 118(6):3629:45. Zimring, C. 2007. “Using Evidence-Based Design to Improve Quality, Safety and the Bottom Line.” Presented at the TRICARE Conference, Washington D.C., 29 January 2007. Fife, d., and Rappaport, E. 1976. “Noise and Hospital Stay. American Journal of Public Health. 66 (7): 68081. Hagerman, IL, Rasmanis, G., Blomkvist, R. S. Ulrich, C., Eriksen, A, and Theorell, T. 2005. “Influence of Coronary Intensive Care Acoustics on the Quality of Care and Physiological States of patients.” International Journal of Cardiology 98:267-270. Busch-Vishnia, I., West, J., Barnhill, C., Hunter, T., Orellana, D., and Chivukula, R. 2005 “Noise Levels in Johns Hopkins Hospital.” Journal of the Acoustical Society of America. 118(6):3629:45. Topf, M. and Dillon, E. 1988. “Noise-induced Stress as a Predictor of Burnout in Critical Care Nurses.” Heart Lung 17 (5):567-74. Joseph, A and Ulrich, R.S. January 2007. “Sound Control for Improved Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.3-4. Ibid, p. 4-5. Ulrich, R., Zimring, C., Quan, W., and Joseph, A. 2004. “The Role of the Physical Environment in the Hospital of the 21st Century.” Concord, CA: The Center for Health Design, web site, www.healthdesign.org, in the Research Reports section. Diette, G.B., Nechzin, N., Haponik, E., Devrotes, A., and Rubin, H.R. 2003. “Distraction Therapy with Nature Sights and Sounds Reduces Pain During Flexible Bronchoscopy: A Complementary Approach to Routine Analgesia.” Chest 123(3): 941-48. Ulrich, R.S. 1984. “View Through a Window May Influence Recovery from Surgery.” Science 224(4647): 420-21. Malkin. J. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 117. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environment’s Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 49.

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Malkin. J. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 117. Heerwagen, J. 1990. “The Psychological Aspects of Windows and Window Design.” In Proceedings of the 21st Annual Conference of the Environmental Design Research Association, edited by K.H. Anthony, J. Choi, and B. Orland. Edmond, OK: Environmental Design Research Association. Chlan, L.L. 2000. “Music Therapy as a Nursing Intervention for Patient Supported by Mechanical Ventilation. American Association of Critical Care Nurses. 11:128-38. Lee, O., Chung, Y., Chan, M.F. and Chan, W.M. 2005. “Music and its Effect on the Physiological Responses and Anxiety Level of Patients Receiving Mechanical Ventilation: A Pilot Study. Journal of Clinical Nursing 14:609-20. Chlan, L.L. 2000. “Music Therapy as a Nursing Intervention for Patient Supported by Mechanical Ventilation. American Association of Critical Care Nurses. 11:128-38. Ibid Chang, S., and Chen, C. 2005. “Effects of Music Therapy on Women’s Physiologic Measures, Anxiety and Satisfaction During Cesarean Delivery.” Research in Nursing & Health 28 (6): 453-61. Lai, H., Chen, C., Peng, T., Chang, F., Hsieh, M, Huang, H., and Change, S. 2006. “Randomized Controlled Trial of Music during Kangaroo Care on Maternal State Anxiety and Preterm Infant’s Responses.” International Journal of Nursing Studies 43:139-46. McCaffrey, R. and Locsin, R. 2004. “The Effect of Music Listening on Acute Confusion and Delirium in Elders Undergoing Elective Hip and Knee Surgery. International Journal of Older People Nursing 13(6b):91-96. Fragala, G. and Bailey, L. 2003. “Addressing Occupations Strains and Sprains: Musculoskeletal Injuries in Hospitals.” AAOHN Journal 51 (6): 252-259. Nelson, A. and Baptiste, A.S. 2006. “Update on Evidence-based Practices for Safe Patient Handling and Movement.” Orthopedic Nursing 25(6), 367-368. American Nurses Association. 2002. Preventing Back Injuries: Safe Patient Handling and Movement. Silver Spring: MD Nelson, A. and Baptiste, A. “Evidence-based Practices for Safe Patient Handling and Movement.” Online Journal of Issues in Nursing. 9 (3), Manuscript 3 at www.nursingworld.org/ojin/topic25/tpc25_3.htm. Joseph, A. and Fritz, L. 2006. “Ceiling Lifts Reduce Patient-Handling Injuries.” Healthcare Design, 6:10-13. Ibid. Engst, C., Chhokar, R., Miller, A., Tate, RB and Yassi, A. 2005. “Effectiveness of Overhead Lifting Devices in Reducing the Risk of Injury to Care Staff in Extended Care Facilities.” Ergonomics 48 (2): 187-99. Chhokar, R. Engst, C., Miller, A., Robinson, D., Tate, RB, and Yassi, A. 2005. “The Three Year Economic Benefits of a Ceiling Lift Intervention Aimed to Reduce Healthcare Worker Injuries.” Applied Ergonomics, 36 (2), 223-9. 110th Congress, 1st Session. HR 378 Nurse and Patient Safety & Protection Act of 2007. Washington D.C. 10 January 2007. Redfern, M and Cham, R. 2000. “The Influence of Flooring on Standing Comfort and Fatigue.” American Industrial Hygiene Association Journal, 61:700-708. Joseph, A. 2006. “The Role of the Physical and Social Environment in Promoting Health, Safety and Effectiveness in the Healthcare Workplace.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.3-4.

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Burgio, L., Engle, B., Hawkins, A., McCormick, K., and Scheve, A. 1990. “A Descriptive Analysis of Nursing Staff Behaviors in a Teaching Nursing Home: Differences Among NAs, LPNs and RNs.” The Gerontologist 30(1): pp, 107-112. Shepley, M.M and Davies, K. 2003. “Nursing Unit Configuration and Its Relationship to noise and Nurse Walking Behavior: An AIDS/IHI Unit Case Study. AIA Academy Journal, http://www.aia.org/aah_a_jrnl_0401_article4. Gardner, Dave. “A technological finger on the pulse of a busy ER.” June 29, 2007. Northeast Pennsylvania Business Journal. Joseph, A and Ulrich, R.S. January 2007. “Sound Control for Improved Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p. 8. Joseph, A. August 2006. “Impacts of Light on Outcomes in Healthcare Settings.” The Center for Health Design web site, www.healthdesign.org, in the Research Reports section Ibid, p. 9. Ibid, p. 5. Morrison, W.E., Haas, E.C., Shaffner, D.H., Garrett, E.H, and Fackler, J.C. (2003) “Noise Stress and Annoyance in a Pediatric Intensive Care Unit.” Critical Care Medicine 31(1): 113-119 Topf, M. and Dillon, E. 1988. “Noise-induced Stress as a Predictor of Burnout in Critical Care Nurses.” Heart Lung 17 (5):567-74. Houston, A., Mitchell, J., Borgani, M., Bumazhny, A. et al. 22 May 2007 “Modern Facility Design and Its Impact on Operational and Capital Investments.” Fitch Ratings, at www.fitchratings.com, p. 2. DeFrances, C.J., Hall, M.J., and Podgornik, M.N. (2005) “2003 National Hospital Discharge Survey: Advance Data for Vital and Health Statistics. Hyattsville, MD: Us Department of Health and Human Services, CDC, National Center for Health Statistics. Hendrich, A., Fay, J., and Sorrells, A. 2004 “Effects of Acuity-Adaptable Rooms on Flow of Patients and Delivery of Care.” American Journal of Critical Care 13(1): 35-45. Schroder, K. 2006 “Designing for Quality: Potential for Facility Design to Elevate Patient Outcomes.” 2007Innovations Center: Health Care Advisory Board, p.11. Mohr, J.J., Batalden, P., Barack, P. 2004. “Integrating Patient Safety into the Clinical Microcosm.” Quality and Safety in Health Care; 13 (Supply II): pp. 1134-38. Doe 10.1136/qshc.2003.009571. Reiling, J. ___ “Designing a Safe Hospital.” Center for the Study of Healthcare Management, Department of Healthcare Management, Carlson School of Management: University of Minnesota, Publication 1 Series. Calhoon, B. 2007. “NCA Patient Focus Group Recommendations”, Personal conversation, 13 February 2007. “Transforming Strategy into Action”, a presentation at the Military Health System (MHS) 2007 Annual Conference, held in Washington, DC, January 29-February 1, 2007. Sadler, B., Hamilton, K., Parker, D., and Berry, L. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 125-143. Hamilton, K. Personal e-mail communication on 4 May 2007. The number that has been floated over the past two years is $6 Billion over the next 5 years for BRACrelated Medical MILCON investments. (This figure may also include some of the Army’s transformation initiatives). Typically, the MHS spends on the order of $300M per year for Medical MILCON, and approximately $1B+ per year on all non-MILCON, Operations and Maintenance (O&M) expenditures.

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