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In Focus: Health Care Leaders Seek to Create Healing Environments for Patients, Staff, and the Broader Community

Summary: There is a substantial body of research demonstrating that the environment in which patients receive care influences their outcomes. And, as more health care facilities seek to "go green," they are finding the link between sustainability and health is even broader.

By Vida Foubister

More than 20 years ago, Roger S. Ulrich, Ph.D., a professor of architecture at Texas A&M University, published an article in Science reporting his findings that surgical patients with a view of nature recovered faster than those with rooms facing a brick wall. Patients recovering with such views also needed less potent pain medication than the brick wall patients.

But it's taken a while for health care facilities to act on such findings, which indicate that a patient's physical environment can have a direct impact on their safety and quality of care.

"The reason being," says Robin Guenther, a leading sustainable health care design architect, "is that the green building tools which were around then didn't make the connection between sustainable building and health."

Since the development of the Green Guide for Health Care, a green building and operations guide for the health care industry, which was piloted in 2004, this has started to change. As of October 2008, 35 health care facilities were LEED certified. LEED, which stands for Leadership in Energy and Environmental Design, is a green building rating system developed by the U.S. Green Building Council. (Though this certification is not specific to health care facilities, which have particular structural and regulatory challenges, LEED for Healthcare is under development.)

Health care leaders also have been influenced by the work of some pioneering institutions to adopt sustainable building plans and operations. These tend to include facilities in environmentally progressive communities, such as Boulder Community Foothills Hospital in Boulder, Colo., which was the first U.S. hospital to earn LEED certification. Religious health care organizations, the missions of which often include being good stewards of God's resources, have also been leaders in this area. St. Mary's Health Care in Grand Rapids, Mich., for example, received LEED certification for the Links Cancer Center, which was sustainably built and completed in 2005.

Whether hospitals and other health care organizations are trying to improve the care environment for their patients, staff, and visitors, or more broadly to protect the planet's health, they are increasingly interested in sustainable design and operations. "The vast majority of clients seeking to begin health care projects now are asking for some level of LEED certification," says Guenther, a principal at Perkins+Will, a commercial architect design firm, and a lead author of the Green Guide for Health Care.

Building Green
There are a growing number of rigorous, peer-reviewed clinical studies that support evidence-based health care design, a process in which decisions about the built environment are based on credible research to achieve the best possible outcomes.

Ulrich and colleagues summarized about 1,000 such studies last year, including those that found relationships between the physical setting of care and the following: patient safety issues such as infections, medical errors, and falls; other patient outcomes such as pain, sleep, stress, depression, length of stay, spatial orientation, privacy, communication, social support, and overall patient satisfaction; and staff outcomes, such as injuries, stress, work effectiveness, and satisfaction. A second paper, published last year by the National Association of Children's Hospitals and Related Institutions, reviewed the pediatric evidence-based design literature (see Related Publications).

Overall, the message is that well-designed health care settings are safer and more healing for patients, as well as being better places for staff to work.

Patients in rooms with exposure to natural daylight, for example, have been found to have better outcomes, says Ulrich. "Natural daylight studies suggest we have to take daylight more seriously. Unless buildings are designed in an architecturally appropriate manner to provide daylight to patients, then there will be significantly higher depression, quite possibility longer stays, and certainly higher levels of pain, with higher operational costs associated with them."

Similar findings hold true for health care workers. Staff who work in rooms with daylight exposure are more likely to report higher levels of job satisfaction than those who don't. Because staff satisfaction ultimately impacts retention, something as simple as ensuring treatment and exam rooms have access to natural daylight can affect a hospital's bottom line.

"Sustainable design is moving more to the center of clinical concerns and actually affecting outcomes, care cost, and care quality for the patient in ways that can be directly measured, which are subject to a financial analysis and payback time analysis in relatively direct manner," says Ulrich.

Research also supports the importance of single-bed rooms, effective ventilation systems, a good acoustic environment, natural distractions such as nature views and gardens, appropriate lighting, good ergonomic design, acuity adaptable rooms, and better floor layouts and work settings, on improving patient outcomes.

While it's more cost-effective to ensure these features are included in an institution's building plans, there are some relatively low-cost improvements that can be made to existing buildings. Switching to ceiling tiles that absorb sound, for example, can improve the acoustics of patient rooms, and better lighting in pharmacy and medication rooms can help to reduce medication errors.

Sustainable Operations
Another evolving component of green health care is to evaluate the impact of a facility's day-to-day operations on patients and staff, as well as the community.

"One of the transformations that health care needs to go through in the next decade or so, is going beyond looking at the individual patient and looking at a much bigger set of factors that contribute to disease," says Gary Cohen, co-executive director, Health Care Without Harm.

Hospitals have, to some extent, started to do this. In 1996, the Environmental Protection Agency reported that medical waste incineration was the greatest source of dioxin contamination in the atmosphere. Since then, hospitals have reduced their red-bag or infectious medical waste and found other ways to dispose of the remaining waste. As a result, the number of incinerators in operation has declined from 5,000 in 1996 to fewer than 100 today. In addition, mercury, a neurotoxin that has been used for decades in thermometers and other measuring devices, is close to being completely eliminated from most U.S. hospitals.

Managers in charge of environmental services—such as those at North Bronx Healthcare Network, which is part of the New York City Health and Hospitals Corporation—have been motivated to evaluate their cleaning products, in part due to the prevalence of asthma in their local community.

"New York City kids are twice as likely to [be hospitalized for] asthma as children in other parts of the country," says Peter Lucey, senior associate director of support services for Jacobi Medical Center and North Central Bronx Hospital, which make up the network. In particular, the Bronx has the highest incidence of asthma in the city.

After switching first to a product that didn't meet their needs, the network identified an economical line of highly concentrated Green Seal–certified cleaners with an advanced dispensing technology. This product is diluted using tamper-proof machines, thus limiting staff exposure to concentrates. Using this product line, the network decreased the number of cleaners in use at both facilities from 11 to three, reduced its waste as a result of the smaller-size containers holding the concentrates, and eliminated staff absenteeism due to accidents, such as splash injuries, and respiratory ailments (Figure 1). It also "saves us money," Lucey says.

Figure 1: Decline in Staff Absenteeism Following North Bronx Healthcare Network's
Switch to Green Cleaners in 2005

Year Injury Reports Lost Staff Days
2004 15 54
2005 9 28
2006 4 7
2007 3 0
2008 1 0

Source: North Bronx Healthcare Network, 2009.

Hospitals have also started looking at the chemicals in their I.V. and blood bags, plastic tubing, and other medical supplies, selecting products without PVCs (polyvinylcholoride) and phthalates. They are evaluating their indoor flooring and selecting options that require less maintenance, and choosing porous paving materials outside, which limit slips and falls. They are using reusable dishes in their cafeterias and buying locally and sustainably grown food. They are also looking to reduce their energy use, in some cases working towards a zero carbon footprint (see Case Study).

"To me, the big message is that there now is a real connection between the kind of physical spaces we care for people and work in and actual patient outcomes," says Blair L. Sadler, senior fellow at the Institute for Healthcare Improvement and past president of Rady Children's Hospital in San Diego. "There is a business case—as well as an ethical case—for building the right kind of environments. It's not about pretty buildings and expensive tapestries on the wall, it's about making better places to care for people and for them to recover."

Green Health Care Organizations

The Center for Health Design is a research and advocacy organization that works to improve health care quality through building architecture and design. Its Pebble Project helps organizations evaluate the effect of a facility’s design on health care quality and organization costs.

Health Care Without Harm is an international coalition of hospitals and health care systems, medical professionals, community groups, health-affected constituencies, labor unions, environmental and environmental health organizations, and religious groups committed to making health care ecologically sustainable.

Practice Greenhealth is a nonprofit membership organization formed from the merger of Hospitals for a Healthy Environment, the Green Guide for Health Care, and the Healthcare Clean Energy Exchange. Its members include hospitals, health care systems, businesses, and other stakeholders “engaged in the greening of health care to improve the health of patients, staff, and the environment.”

U.S. Green Building Council is a nonprofit organization that works to expand sustainable building practices. It developed the Leadership in Energy and Environmental Design (LEED) green building rating system, a third-party certification program and the nationally accepted benchmark for the design, construction, and operation of high performance green buildings.

Related Publications

R. Ulrich, View Through a Window May Influence Recovery from Surgery, Science, April 27, 1984 224(4647):420–421.

R. Ulrich, C. Zimring, X. Zhu et al., A Review of the Research Literature on Evidence-Based Healthcare Design, Health Environments Research and Design Journal, 2008 1(3):61–125.

A. Joseph, A. Keller, and K. Kronick, Transforming Care in Children’s Hospitals Through the Design: Literature Review. In Evidence for Innovation: Transforming Children’s Health Through the Physical Environment (Alexandria, Va.: National Association of Children’s Hospitals and Associated Institutions: 2008:18–47).

B. L. Sadler, A. Joseph et al., Using Evidence-Based Environmental Design to Enhance Safety and Quality (Cambridge, Mass.: Institute for Healthcare Improvement, 2009).

Transforming Hospitals: Designing for Safety and Quality (Rockville, Md.: Agency for Healthcare Research and Quality, September 2007).

Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future (Chicago, Ill.: Joint Commission, 2008).

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