NFPA Journal

Editor’s note: Lynn Kenney, director of industry relations for the Center for Health Design, contributed to this article.

In 2005, Baystate Medical Center (BMC) in Springfield, Massachusetts, launched a process to improve its most outdated buildings and better serve the needs of its expanding patient population. The push to modernize BMC was driven by senior leadership within Baystate Health, with the goal of updating the facility’s aging infrastructure and double-occupancy patient rooms.

BMC had served as a cornerstone of the region’s health care infrastructure for well over a century. The hospital’s roots extended back to 1870, when Springfield City Hospital was just one of 178 acute care hospitals in the United States. It was renamed Springfield Hospital in 1883 and moved to its current location in 1889. Today, BMC is the largest hospital within the Baystate Health System, a multi-institutional, integrated health care organization serving 750,000 people throughout Western New England. BMC has been recognized nationally for quality, safety, and critical care excellence, and has received magnet recognition by the American Nurses Credentialing Center (ANCC), a distinction that places the hospital’s nursing staff among the finest in the nation.

The improvement process began with the formulation of a 15-year master plan devised by a steering committee that included executive board members, clinical leaders, and facility management. The plan called for the replacement of an outdated patient tower with a multi-phased extension consisting of three new patient towers.

The extension would add 640,000 square feet to BMC, expanding its acute care and inpatient services, adding a combined heart and vascular center, developing medical, surgical, and critical care beds, expanding the emergency department capacities, and relocating the children’s hospital—in short, creating a “hospital of the future.” About 45 percent of the extension would be built as shell space for future growth.

The master plan consisted of multiple phases, four of which are complete. Phase 1 construction, begun in 2009 and completed in early 2012, included the extension’s shell and core—building the entire 640,000-square-foot shell at the outset would help save money over the course of the multi-year project—plus 300,000 square feet of interior fit-out for a heart and vascular center, six hybrid operating suites, 96 medical/surgical inpatient beds, and 30 intensive care beds. Phase 2, completed in 2012, included the build-out of the lobby renovations and café. Phase 3 included the replacement of the existing emergency department with a 94-bed emergency and Level-1 trauma center, and was also completed in 2012. Planning for the Phase 4 South Wing, which would include 76 medical/surgical inpatient and 20 intermediate-care beds, began in 2012, and the wing opened in 2016. BMC now occupies more than a million square feet and serves more than 80,000 patients annually.

The large U-shaped addition added 640,000 square feet to Baystate Medical Center. The Phase 1 buildout, shown in purple, included a heart and vascular center, operating suites, and patient beds, and was completed in 2012. An evidence-based process was applied to Phase 1 and informed the buildout of the Phase 4 wing, shown in blue, which included nearly 100 patient beds and was completed in 2016. Photograph: Steffian Bradley Architects

My role in Baystate’s Phase 4 South Wing effort was as project executive with Steffian Bradley Architects (SBA), a global design firm based in Boston. One of our areas of specialization is healthcare planning, and the steering committee at BMC selected the design team at SBA to develop and implement the 15-year master plan. As part of our approach for developing the Phase 4 patient areas, we used evidence-based design, or EBD, an eight-step process that can help the industry make informed, research-based decisions about the built environment to achieve the best possible outcomes. In late 2012, after the Phase 1 patient areas had been operating for about nine months, we conducted post-occupancy evaluations—critical components of EBD—of those areas and used the information to make important design changes in the Phase 4 South Wing patient areas.

In today’s health care ecosystem, where Medicare/Medicaid reimbursements are based on quality measures like safety, infection rates, readmissions, and patient satisfaction, building design is a critically important aspect of a health care facility’s ultimate success. A growing body of evidence illustrates how the built environment impacts delivery of care, patient safety, and patient experience. Building components such as layout, lighting, wayfinding, acoustics, access to nature, temperature control, and air quality all play important roles in creating an environment that improves outcomes and efficiency, and supports healing. When used alongside codes and standards such as NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities, evidence-based design, as illustrated by the Baystate project, is a valuable tool for achieving a compliant design that is both functional as a built environment and effective as an environment in which to heal.

Despite its benefits, EBD remains an under-utilized process. I hope the overview of EBD provided here, and its application in the Baystate project, can shed some light on the benefits of applying these eight steps to health care facility renovation and construction. The Baystate project illustrates the importance of investing in design strategies that are based on research and informed stakeholder input, resulting in improved safety, delivery and experience of care, and return on investment.

1. DEFINE EVIDENCE-BASED GOALS AND OBJECTIVES

The first step in applying the evidence-based design process is the creation of an interdisciplinary team to establish a vision that defines the intentions, direction, and objectives for the project. Defining goals based on evidence and research helps ensure better outcomes and a better return on investment.

Baystate recognized the importance of assembling its multi-disciplinary team early in the process to ensure input from all stakeholders. Members of this team represented the hospital’s administration and clinical staffs, as well as its nutrition and pharmacy staffs. It included an array of people involved in the design and construction of the new addition, including project managers, engineers, and environmental services specialists. And it included patients and families—virtually anyone involved in the delivery and receipt of care was represented in the design and evaluation meetings. Critics of this process sometimes complain that it adds time to a project, but receiving input from key stakeholders and reviewing evidence-based goals helps minimize change orders and ensures that the final design meets the goals of the organization.

Key EBD goals were identified to improve the efficiency of the hospital and the daily experience for patients, families, support staff, and caregivers; improve the design and physical environment of the hospital; and improve the facility’s safety and security, quiet and privacy, access and wayfinding, patient rooms, and bathroom design. For example, EBD goals led to the creation of off-stage and on-stage work and support areas in the clinical suites. The “on-stage” corridor was designed for use by patients, care teams, families, and visitors, while an “off-stage” corridor linked directly to support elevators, providing supply carts with a connection to support rooms while reducing noise and clutter in the patient corridor. An especially important goal was to create single-occupancy patient rooms and efficient unit layouts to improve satisfaction, care efficiency, and safety.

2. FIND SOURCES FOR RELEVANT EVIDENCE

This step usually involves a literature review to identify relevant research and to identify gaps in knowledge and opportunities for future research studies.

Several types of evidence were used to help inform BMC’s design decisions. A number of research studies and case studies are cited in the project bibliography, including a well-known study demonstrating that patients who have rooms with views of nature request fewer doses of pain medication, experience fewer complications, and recover faster than patients with views of brick walls. Post-occupancy evaluations were conducted with BMC patients; the 96 patient rooms built in Phase 1 were designed to be in use for 8–12 months so that the project and design team could assess how well the initial patient room design worked in meeting the intended goals. Building mock-ups based on the Phase 1 feedback helped the team see and experience the design in 3D so that they could test and experience the actual layout and design.

Sources of evidence also included surveys and interviews, where patients and family members who had stayed in the single-occupancy rooms were asked to review the room design and to rank the importance of room features such as lighting, room temperature, access to personal and medical technology, staff visibility, and visitor accommodations. Additionally, the design team shadowed the clinical team on the inpatient bed floors for multiple days, targeting various hours of the day to identify areas for improvement. Those included configurations for care team “on-stage” locations, as well as patient headwalls, the architectural features in patient rooms that merge electrical and medical gas functions into single units to maximize efficiency.

3. CRITICALLY INTERPRET RELEVANT EVIDENCE

This EBD step involves analysis of the relevant research to determine if the evidence is credible and can be used to inform the project design and hypotheses.

A decision was made early on in the planning process to design single-patient rooms. This decision was supported by industry research indicating that single-patient rooms improve sleep and healing and contribute to reduced infection rates. Post-occupancy survey results at Baystate confirmed that shifting from double to single rooms had a positive impact on patients, families, and staff.

4. CREATE AND INNOVATE EVIDENCE-BASED DESIGN CONCEPTS

In this step, the team translates the relevant evidence into design guidelines and preliminary design concepts.

At Baystate, the evidence-based design process could lead to unexpected innovations. The ability to involve the contractor, major trades, and life safety consultant early in the planning process and keep them involved through the project helped the team at Baystate meet the intended aesthetic and safety goals and realize cost savings.

For example, because the project’s life safety consultant, Code Red Consultants, was involved in the planning process, they were able to identify a more cost- effective smoke damper design. This resulted in more than $100,000 in savings, as well as ongoing savings in time and money needed to maintain and test the dampers. The insights gained from this type of innovation can also improve code language so that everyone can benefit from this type of success.

5. DEVELOP A HYPOTHESIS

In the EBD process, hypotheses help guide data collection and provide guidance for analyzing and interpreting the data.

The BMC project team hypothesized that the design and location of the care team stations could be optimized to improve interdisciplinary communication, which in turn could lead to improvements in staff satisfaction, patient satisfaction, safety, and outcomes.

The team also hypothesized that equipment in the patient room design in Phase 1 could be developed further to provide a safer, more ergonomic space to improve the healing environment. For example, the Phase 1 location of the computer at the headwall was in conflict with the staff’s ability to access the button for code blue, which requires immediate action by additional care team members. This potential problem was improved in the Phase 4 headwall mock-up by relocating the code blue button, allowing staff direct access to the button without inferring with the wall-mounted computer.

6. COLLECT BASELINE PERFORMANCE MEASURES

In this step, the design team assesses current processes at a macro level and defines the project metrics that will be used to measure outcomes.

Prior to designing the Phase 4 South Wing patient tower, the team collected baseline performance measures based on patient surveys in the Phase 1 West Wing single-occupancy rooms. Survey data suggested that patients enjoyed greater satisfaction with the single occupancy rooms compared to the older units on Baystate’s campus: 90 percent felt patient rooms were quiet at night, compared to 75 percent before; 95 percent felt rooms and bathrooms were clean, compared to 89 percent before; and 95 percent felt lighting and temperature controls created a comfortable environment, compared to 75 percent before.

Survey feedback led to meetings with Baystate’s patient family advocacy group. Representatives offered insight into which features impacted the feel and functionality of patient rooms. Families appreciated the three separate room zones for nursing, patients, and family space, as well as the warm wood tones of the décor. The natural wood headwall was part of the desired impression of hospitality, making patients and visitors feel more comfortable. Lighting fixtures for reading were key. Less important, however, were the tiling and sconce along the footwall, which patients had neither noticed nor used. Millwork platforms and shelving were eliminated because patients and physicians were not putting them to use.

A number of changes were made to the Phase 4 wing as a result of the evidence-based evaluation of the Phase 1 wing. Here, a Phase 1 inpatient room headwall is shown at top, with Phase 4 changes, as well as elements that were kept, indicated below. 1. Removal of sconce not used by patients; 2. Removal of custom light soffit, replaced with light fixture that maintained varying light levels; 3. Maintained nursing zone with separate lighting; 4. Kept warm wood tones to maintain the desired hospitality aesthetic. Photograph: Steffian Bradley Architects

The interdisciplinary team survey confirmed problematic distances between nurse stations in Phase 1. Line-of-sight was limited; since staff assignments were spread out, nurses could not see all patient rooms from a single workstation. Off-stage areas were highly successful, reducing the noise of cart traffic in corridors and adding team spaces to engage clinical team collaborations. Since Phase 1 work areas lacked direct access to main corridors, Phase 4 added a door and windows for more direct connections between work areas, corridors, and nurse stations. The decentralized stations of Phase 1 were consolidated into larger stations, with corner nurse stations connected by open work areas so staff could see each other between stations. Direct links were built between off-stage team areas and nurse stations.

7. MONITOR IMPLEMENTATION OF DESIGN AND CONSTRUCTION

This step allows adjustments to be made and for input to be provided throughout the process. The project team ensures that design strategies are executed as specified in the design documents.

In the Phase 1 West Wing patient rooms, custom wood valances that had been included over the headwalls and footwalls were not cost effective. Even so, design team members worried about removing this design element. A simple prefabricated valance was found, and was installed and evaluated in the mockup. The team quickly realized that the prefabricated valence would work out much better from a maintenance and cost standpoint while achieving the same aesthetic as the custom-built component. This single change represented a savings of between $80,000 and $90,000 in up-front costs, with additional savings over time in maintenance costs.

8. MEASURE POST-OCCUPANCY PERFORMANCE RESULTS

In the final step, the team implements the research study as outlined in the plan to determine if the design is performing as intended. This critical step can help inform future designs, but it is often the most underutilized step in the process, since it can be difficult and time-consuming to conduct post- occupancy research once the facility becomes operational.

Using post-occupancy data, the BMC team learned that patients want quiet—but not too much quiet. Patients and families sometimes felt isolated in the Phase 1 West Wing because they reported that it was too quiet. They also reported that they were unable to find staff at the nurses’ stations; while the number of nurses’ stations had been increased, meaning a reduction in the number of steps for the care teams, it also meant fewer staff at each station, resulting in both the nursing staff and patients feeling more isolated. The interdisciplinary project team used all of this data to improve the design of the Phase 4 South Wing. Instead of the seven small nurse stations that had been included in Phase 1, the new design called for four slightly larger stations.

Going forward

With the help of the evidence-based design process, the Baystate Phase 4 South Wing project was completed three months ahead of schedule and with more than a million dollars in cost savings.

Unfortunately, Baystate is an impressive but uncommon success story, as EBD remains an underutilized, underappreciated tool for health care stakeholders to get the most out of the design and construction process. Building the hospital of the future in multiple phases allows the team to take time between phases to learn from previous designs and operational models.

As part of its effort to create a "hospital of the future," BMC has incorporated patient-oriented elements, including a "healing garden." Photograph: Robert Benson

I’ve worked on a number of health care projects in recent years where evidence-based design was utilized and informed the design, enhancing the operational model and allowing for flexibility and growth in the facility. Those are the kinds of lessons learned that can and should be applied to other projects. This kind of project management innovation is urgently needed in this time of increasing health care regulatory pressure and decreasing budgets.

Baystate has taken the lessons to heart. A third new patient wing is slated to begin construction sometime in the next 3–5 years, and the team, including Baystate and its design and construction partners, plans to implement the same evidence-based design process to continue to improve the BMC campus.

KIRSTEN WALTZ is president of U.S. operations for Steffian Bradley Architects. Top Photograph: Steffian Bradley Architects