January-February 2011 HASTINGS CENTER REPORT 23

Nursing Quarterly(2006);Hendrich,Fay,andSorrells,“EffectsofAcu-ity-AdaptableRoomsonFlowofPatientsandDeliveryofCare.”

24.W.E.Bischoffetal.,“HandwashingCompliancebyHealthCareWorkers:TheImpactofIntroducinganAccessible,Alcohol-BasedHandAntiseptic,”Archives of Internal Medicine160,no.7(2000):1017-21;D.Pittet,“ImprovingCompliancewithHandHygieneinHospitals,”Infection Control and Hospital Epidemiology21,no.6(2000):381-86;D.Pittetetal.,“EffectivenessofaHospital-WideProgrammetoIm-proveCompliancewithHandHygiene,”Lancet356(2000):1307-12.

25.T.L.Buchananetal.,“IlluminationandErrorsinDispensing,”American Journal of Hospital Pharmacy48,no.10(1991):2137-45;M.CohenandJ.Smetzer,“ISMPMedicationErrorReportAnalysis:SafePracticeEnvironmentChapterProposedbyUnitedStatesPharmaco-peia,”Hospital Pharmacy44,no.3(2009):210-13;RevisionBulletin,“PhysicalEnvironmentsthatPromoteSafeMedicationUse,”inPhar-macopeial (Washington,D.C.:U.S.Pharmacopeia,2010).

26.V.Blomkvistetal.,“AcousticsandPsychosocialEnvironmentinIntensive Coronary Care,” Occupational and Environmental Medicine62,no.3(2005):132-39;I.Hagermanetal.,“InfluenceofIntensiveCoronary Care Acoustics on the Quality of Care and PhysiologicalStateofPatients,”International Journal of Cardiology98,no.2(2005):267-70.

27.Green Guide for Health Care: Best Practices for Creating High Per-formance Healing Environments (Washington,D.C.:GreenGuide forHealthCare,2007);Houghton,Vittori,andGuenther,“DemystifyingFirst-CostGreenBuildingPremiumsinHealthcare.”

28.Ibid.29.M.J.Breslowetal.,“EffectofaMultiple-SiteIntensiveCareUnit

TelemedicineProgramonClinicalandEconomicOutcomes:AnAlter-nativeParadigmforIntensivistStaffing,”Critical Care Medicine32,no.1(2004):31-38;E.J.Thomasetal.,“AssociationofTelemedicineforRemoteMonitoringofIntensiveCarePatientswithMortality,Compli-cations,andLengthofStay,”Journal of the American Medical Association302(2009):2671-78.

30.B.L.SadlerandA.Ridenour,Transforming the Health Care Ex-perience Through the Arts (San Diego, Calif.: Aesthetics, Inc., 2009);S.M.Schneideretal.,“VirtualRealityasaDistractionInterventionforWomen Receiving Chemotherapy,” Oncology Nursing Forum 31, no.1 (2004): 81-88; R.S. Ulrich, O. Lunden, and J.L. Eltinge, “Effectsof Exposure to Nature and Abstract Pictures on Patients RecoveringfromHeartSurgery,”Psychophysiology30,suppl.1(1993):7;O.Good-man,ed.,2009 State of the Field Report:Arts in Healthcare(Washington,D.C.:SocietyfortheArtsinHealthcare,2009).

31. D. Evans, “The Effectiveness of Music as an Intervention forHospitalPatients:ASystematicReview,”Journal of Advanced Nursing37,no.1(2002):8-18;J.M.Standley,“AMeta-AnalysisoftheEfficacyofMusicTherapyforPrematureInfants,”Journal of Pediatric Nursing17,no.2(2002):107-113.B.Thorgaardetal.,“SpeciallySelectedMu-sicintheCardiacLaboratory:AnImportantToolforImprovementoftheWell-BeingofPatients,”European Journal of Cardiovascular Nursing: Journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology3,no.1(2004):21-26.

32.C.CooperMarcusandM.Barnes,Gardens in Healthcare Facili-ties: Uses, Therapeutic Benefits, and Design Recommendations(Martinez,Calif.:CenterforHealthDesign,1995).

33. D. Berwick, “Eating Soup with a Fork,” keynote address atthe Institute for Healthcare Improvement 19th Annual Forum, Or-lando, Florida, December 2007, available at http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/OnDemandPresentationBerwick.htm?player=wmp.

34.Sadleretal.,Using Evidence-Based Environmental Design to En-hance Safety and Quality.

Severalyearsago,webuiltanewhospitalfromthegroundupinDublin,Ohio,fortheOhioHealthsystem,andwefound ourselves presented with an opportunity to try

toputtheFablehospitalconceptintopractice.Thisplannedninety-four-bed communityhospitalwas intended to servethegrowingnorthwestquadrantofFranklinCounty,alongwithareastothewestandnorthwest.WithtertiaryfacilitiesalreadyapartoftheOhioHealthsystem,DublinMethodistwas intended to provide primary and secondary care. Ourgoalwastobeasinnovativeaswecouldaffordtobe,tochal-lenge the statusquoatevery turn.Our statedpurposewasto “redefine the way patient care is provided” through thedevelopment of a less-stressful healing environment, withanemphasisonpatientsafetyandthepatient/familyexperi-ence.Inaddition,wepromisedthecommunityahighlevelofcustomerserviceandelectedtoincorporateafullyelectronicmedicalrecordmanagementsysteminthenewfacility.Thesenior leadershipandtheboardofdirectorsofOhioHealthfullysupportedtheseefforts.

Whenplanningbeganin2004,itwasapparentthatevi-dence-baseddesigncouldhelptoachievemanyofourgoals.We became aware of evidence-based design from RosalynCama,aconsultantonourarchitecturalteamwhosupporteditsuseandemployeditsprinciples.TheFablehospitalarticleprovidedguidanceaswebeganourdesignjourney.

Firstandforemost,wechosesingle-bedrooms,althoughtheywerenotrequiredbytheAmericanInstituteofArchi-tectsuntil2006.Theevidenceforthisdecisionwasstrong;

CaseStudy:Dublin Methodist Hospital

BY CHERYl HERBERT

CherylHerbert,“CaseStudy:DublinMethodistHospital,”Hastings Center Re-port41,no.1(2011):23-24.

24 HASTINGS CENTER REPORT January-February 2011

whilesingleroomscreateadditionalsquarefootageandmoreexpenseduringconstruction,buildingthemwasclearlytherightthingtodo.Privateroomssupportedourcommitmenttopatient safety, as theyhavebeen shown to reduce infec-tions, medication errors, and falls. Noise levels are lower,communication isenhanced,andsocial support iseasier toprovideinroomswithonlyonepatient.Allofthesebenefitscontributed toboth thehealing environment and the levelofcustomerservicewewishedtoensure.Privateroomswithdoorswerealsobuiltintotheemergencydepartment,aswellasthepre-andpostoperativetreatmentarea.Atnotimeintheirjourneythroughourbuildingdopatientssharearoom.

Becauseofthepositiveeffectsofnaturallight,suchasitscontributiontoabettermentaloutlook,wealsochosetoin-corporatewindowswhereverwecould,resultinginaccesstodaylightinapproximately90percentoftheoccupiedspacesinthebuilding.Therearewindowsinallinpatientroomsandmostemergencydepartmentrooms,inadditiontothecorri-dorssurroundingoursurgerysuites,manyofficesandadmin-istrativespaces,andallpublicareas.Fouropen-aircourtyardsenhancetheaccesstonaturallightandallowpeopletostepoutside.

Thenaturethemeisconsistent,withlivetrees,plants,anda three-and-a-half-storywaterfall in themainatrium.Treesalsoservetobringnaturetotheemergencydepartmentwalk-inpatientlobby,andenlargedphotographsofnaturalscenesarescatteredthroughoutthebuilding,servingasbothstressreducersandway-findingclues.Naturalmaterialswereusedwheneverpossible,andthecolorsofflooringandwallswerechosenforboththeirtimelessnessandtheirrepresentationoftheoutsideenvironment.Since thereare fewninety-degreeanglesinnature,manyofourwallsandsoffitsarecurvedtosoftentheappearanceofcorridorsandcorners.

Noiseisastressorandadistractionthatweaimedtomini-mize in this facility.Measures taken to reduce sound levelsincludeacousticceilingtilesthroughoutthebuilding,carpettiles in the hallways of inpatient units, ceilings of variousheights,patientbeds inpavilionsoutofmainstream trafficpatterns,andtheuseofahands-free,wirelesscommunicationdevice.Thisdeviceiswornbyallemployeesandhaselimi-nated theuse of overheadpaging except in cases of publicemergency(atornadowatch,forexample).

Webuiltsixtyacuity-adaptableroomsbecausetheywouldallowustoleavepatientsinplaceregardlessofhowsicktheyareduringtheirstay.Wemadethisdecisionbecauseevidenceshowed that each time a patient is transferred and handedofftoanewteamofcaregivers,thepossibilityofmedicaler-rorincreases,patientandfamilystressincreases,andpatientbelongings areoftenmisplaced, to saynothingof the timeandenergyrequiredfromstaff.Withacuity-adaptablerooms,asapatient’sconditionchanges,staffandtechnologycanbemovedinandoutoftheroom.

Wetooka leapof faithwhenwedecidedtostandardizethe layout of as many spaces as possible.The evidence inthisareawasnotasstrongasinothers.Standardizationhasproventodramaticallyincreasesafetyinotherindustries,so

we surmised that it would help reduce errors in medicine.Particularlyduringanemergency,staffdoesnothavetotaketimetorememberwheretofindsomething,aseverythingislocatedinthesameplaceineachroom.Standardizationwasappliedtoinpatient,emergencydepartment,x-ray,andlaborand delivery rooms, as well as surgical suites and pre- andpostoperative rooms. Our inpatient rooms have the bath-roomontheheadwalltokeeppatientsfromhavingtocrosstheroomwithnosupport.

Threeyearslater,theresultsaregood.Ifwehadittodoover,wewouldlocateacoupleofthingsdifferently—forex-ample,wewouldmove the sterileprocessing area closer tothesurgerydepartmentandmaketheoutpatientareasabout50percentlargertoaccommodateanunexpectedincreaseinthenumberofoutpatients.Butbyandlarge,theefforthasliveduptoourexpectations.Fromopeningday inJanuary2008,patientsatisfaction,asmeasuredbyanationalsurveyinstrument,hasbeenoutstanding.Theresponsesshowthatweachievedourgoalsinrelationto“noiselevelinandaroundmyroom,”whichconsistentlyranksintheninety-ninthper-centile for satisfaction, as well as in accommodations forfamilyandvisitorsandotheraspectsofsatisfactionwiththeroominwhichtheystay.Patientsarealsoaskedwhethertheythoughttheircarewasprovidedinasafemannerandwheth-erstaffroutinelywashedtheirhands.Theseresultshavealsorankedconsistentlyintheninetiethpercentileandabove.

Healthcare-acquired infectionshaveoccurredatacom-paratively lowrate,ashavepatient fallswith injury.Wedonotyetknowhowmuchthe standardized layout improvedpatient safety. Comparisons with similar hospitals are hardtomakebecausethatinformationisn’tpubliclyavailable,butourinfectionrateisabout0.5peronethousandpatientdays,lower than thosedocumentedby theNationalNosocomialInfections Surveillance System. Our electronic medical re-cordsandanelectronicsystemfororderinganddistributingmedication,whichdouble-checks foraccuracy,havealmosteliminatedseriousmedicationerrors.

Althoughvolumeswereabitslowwhenweopened,Dub-linMethodisthasexceededvolumeandfinancialexpectationssinceDecember2008andcontinuestogrowatasteadypace.Wecalculatethattheevidence-baseddesignelementswein-corporatedwere2.5percentofthetotalprojectcostof$150million.Ourresultstellusitwasworthit.