Research Report. Evidence-based design

Transcription

1 Research Report Evidence-based design Evidence-based design Executive Summary Research Report With the aim of enhancing the built environment, an evidence-based design (EBD) approach involves multidisciplinary planners continually assessing hypotheses while making use of past research into the impact of different design strategies. EBD has recently excited considerable interest among healthcare facility managers, designers and architects who believe it can improve the quality and safety of care, patient satisfaction and staff morale. This report investigates the concept of EBD, its place and use within the healthcare sector and the benefits that can accrue from using the approach. It also serves as a literature review and contains a summary of representative case studies. One of the main driving forces behind the application of EBD in healthcare facilities is the goal of reducing hospital-acquired infections (HAIs), other factors such as reductions in medical errors, pain, stress and length of stay are also important (Ulrich et al., 2008). The most visible indication of EBD in practice may be changes in patient accommodation, with single-bed rooms representing the design intervention that contributes most to positive patient outcomes (Ulrich et al., 2008). Other common changes resulting from EBD are the installation of ceiling-mounted lifts and the decentralisation of large nursing areas with the freed space utilised for other purpose (The Center for Health Design, 2008). In addition to its advantages from the viewpoints of patients and healthcare staff, EBD appeals to healthcare organisations due to the potential of enhancing operational efficiency and financial performance (Hamilton and Watkins, 2009). The EBD process can be summarised thus: Define goals and objectives; Critically interpret available evidence; Develop design concepts to achieve hypothesised performance outcomes; Following implementation (ideally on a pilot basis), outcomes are measured and shared with other groups. The report discusses strategies that may prove useful in the implementation of successful EBD projects before examining exactly what is meant by evidence, how it is gathered and how it may be analysed. The importance of executive level leaders in driving an institutional and cultural change which is likely to involve the support of a patient-centred ethos is highlighted and the views of several researchers on the possible financial advantages of EBD are given. A summary of the information gleaned from the case studies confirms that the benefits expected from EBD were largely borne out. The report concludes with the following recommendations. NHSScotland should: May 2011 Page 1 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

2 consider EBD appropriate only for facilities that will be retained and used by the organisation well into the future; confer with the staff and managers of facilities to determine individual goals and where improvements are needed; gather and analyse evidence and information that could be of assistance in supporting future design modifications; develop design concepts that could achieve desired outcomes and test various hypotheses; collect relevant baseline performance measures for each facility; ensure the hypotheses undergo pilot-testing through the use of mock facilities; develop an education and support programme that will enable staff to familiarise themselves with forthcoming developments; implement the EBD modifications; assess the efficacy of the designs based on the baseline monitoring data that was collected and subsequently share results with other organizations. May 2011 Page 2 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

3 Background It has been suggested that the design or renovation of NHSScotland healthcare facilities be carried out with systematic use made of research and previous experience. In order to assist NHSScotland managers it was accordingly recognised there was a need to accumulate information surrounding evidence-based design. Research Question/Title of work What is evidence-based design? What are the contributing factors, benefits, costs, strategies and support requirements of evidence-based design? How have other organisations approached and incorporated evidence-based design concepts into their health environments and what benefits have been achieved through their efforts? Summary The strategy of evidence-based design has become increasingly popular in relation to healthcare facility planning. This report examines the background to the topic and highlights the advantages of the approach. A series of recommendations is made on how best to carry out the evidence-based design process to those wishing to implement it in their healthcare facilities. Abstract Evidence-based design (EBD) is the process of using research and hypotheses to test, develop and justify design decisions. EBD is anticipated to fill a much needed gap in healthcare by reducing system-based errors and increasing the safety and quality of care. This report investigates the concept of EBD, its place and use within the healthcare sector and the benefits that can accrue from using the approach. The report also identifies the different ways in which practitioners of EBD can use the methodology and presents several processes and strategies that can be used in its implementation. Other aspects addressed are the research element involved, the supporting needs and the possible costs associated with the procedure. The report concludes with a review of twelve case studies in which an EBD approach has been used. A series of recommendations is made should NHSScotland consider using EBD in its facilities. Method The information contained in this report was obtained from a variety of sources: books, journals and online material. The report serves as a literature review and a summary of representative case studies. May 2011 Page 3 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

4 Inclusion and Exclusion criteria Inclusion creteria Comprehensive, yet user-friendly information from high-standing organisations. Government studies. Peer reviewed studies. Well-developed case studies (including international sources). Exclusion criteria Information from unknown organisations or websites. Case studies with insufficient details. Search terms to be used include: evidence-based design; evidence-based design strategies; evidence-based design process; evidence-based design + Healthcare; evidence-based design + Scotland; evidence-based design + UK; evidence-based design + case studies. May 2011 Page 4 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

5 Introduction In Scotland, 1 in 10 acute-care patients and 1 in 13 non-acute-care patients are affected by a healthcare-associated infection (HAI), costing NHSScotland 183 million per year (Health Protection Scotland, 2010) and 2,105 per infected acute-care patient (Cameron, 2009). These infections are responsible for 50,000 deaths per year in the UK and lengthen hospital stays by 70% (Reilly and Leaper, as cited in Ethicon, 2008). In the United States, 1 in 20 hospital patients experience a HAI each year, resulting in 88,000 deaths and $4.5 billion in extra costs (Ranji et al. as cited in The Center for Health Design, 2008). Preventable adverse drug events also occur 380,000 to 450,000 times per year in US hospitals, 800,000 times per year in long-term facilities and 530,000 times per year in outpatient settings for Medicare patients (Institute of Medicine, as cited in The Center for Health Design, 2008). These statistics underline a need to reduce system-based errors (Sadler as cited in Sadler et al., 2008) and a possible solution, commonly referred to as evidence-based design, stems from the realisation that physical surroundings can have an appreciable impact on patient outcomes (see, for example, The Center for Health Design, 2008). Evidence-based design (EBD) can be described as a philosophy whereby managers, architects and designers make decisions governing healthcare environments by acting upon rigorous research into the impact of design strategies. It may therefore be viewed as a practice [is] based on evidence rather than the personal opinions or habits of clinicians (Ferlie et al., 2009, p. 837). EBD has been found to reduce staff and patient stress and improve patient safety and overall healthcare quality (The Center for Health Design, 2008). A well-designed physical environment can also eliminate or reduce patient falls and HAIs (Sadler et al., 2008). Moreover, views of nature, good sunlight, ventilation and perceived environmental control have been found to improve bedpatient recovery times (Lawson et al. as cited in Stevenson et al., 2010). Conversely, the poor design of hospital units can result in increased noise levels which affect sleep, communication and healing, while multi-bed patient rooms, poor air quality and a lack of hand-washing facilities can cause a rise in HAI rates (Harris et al., 2008). A facility s design can also have a significant impact upon healthcare staff. A facility that possesses poor design, layout and communication technologies may prevent staff from properly assessing and caring for their patients (Page, as cited in The Center for Health Design, 2008). As stated by Hendrich et al. (as cited in Hendrich & Chow, 2008), elements of the current hospital work environment, including inefficient work processes and physical designs, gaps in technology infrastructure and unsupportive organisational cultures, contribute to inefficiencies and stress for hospital nurses, limiting the time they can spend in direct patient care (p. 2). This report aims to investigate EBD and examine its benefits, strategies, methods, costs and supporting requirements. Several case studies will also be explored to determine how EBD has been used by various organisations to improve patient safety and satisfaction and the quality of care provided. The resulting information will be used to determine how to incorporate EBD within NHSScotland s domain. May 2011 Page 5 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

6 Review findings Definition of Evidence-based design The term evidence-based is increasingly used in the context of activities such as management, government policy formulation, pharmacy and medicine. It is generally understood to denote the systematic use of past experience in decision-making and the principle has been widely applied to design of the built environment. Evidence-based design (EBD) can be defined as a process involving the reorganisation of thinking, the in-depth investigation and gathering of research, the development of scientific questions and hypotheses and, ultimately, the testing of creative and innovative design solutions (Cama, 2009). Hamilton and Watkins (2009) state that EBD surrounds the conscientious, explicit, and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project (p. 4). In addition, Harris et al. (2008) state that evidence-based design processes apply knowledge about the actual performance of built environments in the real world to achieve clients and other stakeholders most significant goals (p. 2), while The Center for Health Design (2008) believes it is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes (p. 2). Although each definition may differ slightly, the key factor within these explanations and which differentiates EBD from traditional design is the emphasis on research and prior experience and how this information is used to make educated design decisions and evaluate innovative approaches (The Center for Health Design, 2008). In a healthcare context, Harris et al. (2008) state that EBD is a process that links building design decisions to positive outcomes that have been systematically assessed in previous situations, such as increases in patient satisfaction, decreased infections and reduced numbers of falls. As such, EBD is often value-driven, with specific goals of improving certain areas of an organisation (The Center for Health Design, 2008). It must be noted that EBD is not intended to replace good judgement and design experience but to provide a strategy and direction through which design issues can be addressed or questioned (Harris et al., 2008). Evidence-based design and Healthcare facilities Western healthcare systems have been experiencing a major growth in hospital building in order to cope with the increasing burden imposed by the Baby Boom generation and the introduction of new medical technologies (Ulrich et al., 2008). This construction programme gave opportunity to improve the design of hospitals in order that various issues are addressed, particularly patient safety concerns such as the number of hospital-acquired infections (HAIs) and medical errors (Ulrich et al., 2008). There is an increasing tendency in the United States to use EBD as the means of relating hospitals physical environments to healthcare outcomes, with 50 providers and manufacturers and the Military Health System being committed to the principle (Ulrich et al., 2008). The NHS, which has the advantage of being able to act at a national level to foster system-wide change quickly (Building Better Healthcare, n.d.), is also interested in EBD. May 2011 Page 6 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

7 The most detailed review of EBD in healthcare with regard to specific outcomes is provided by Ulrich et al. (2008), who examined nearly 500 papers and reports. The Ulrich report (2008) put forward a number of areas where EBD is helpful, the areas included reductions in HAI s, patient falls, medical errors, pain, patient stress, patient depression and length of patient stay; it also included improvements in staff outcomes. The key points regarding use of EBD in these areas are summarised as follows: Reducing Hospital-Acquired Infections The research literature supported the following design measures: use effective air quality control measures during construction and renovation to prevent the outbreak of airborne infections. Measures include using portable highefficiency particulate air (HEPA) filters, installing barriers between patient-care areas and construction/renovation areas and sealing patient windows; install alcohol-based hand-rub dispensers at the bedside and in other accessible locations to increase hand-washing compliance and reduce contact time of transmission; select easy-to-clean floor, wall and furniture coverings and employ proper cleaning and disinfection procedures; design and maintain the water system at the proper temperature and adequate pressure, minimise stagnation and back flow, eliminate dead-end pipes, regularly clean point-of-use fixtures, consider the location of decorative fountains and carefully maintain them to minimise the risk of waterborne infection; provide single-bed rooms with private toilets to enable separation or isolation of patients on admission so that those with unrecognised infections can be tested and identified without being mixed in with uninfected individuals in multibed rooms. To reduce airborne infection transmission, increase isolation capacity and facilitate the maintenance of good air quality through measures such as effective ventilation, filtration and appropriate air flow direction and pressure (positive or negative). To facilitate thorough cleaning after a patient leaves, including the use of decontamination methods such as hydrogen peroxide vapour (HPV), which may be much more effective than conventional cleaning. Reducing medical errors The limited literature available shows that environmental factors can play an important role in causing medical errors and, therefore, environmental approaches can correspondingly reduce errors. There is limited evidence that prescription error rates increase sharply when there is an interruption or distraction from an unpredicted noise. Poor lighting levels can affect the performance of healthcare workers and lead to medical errors. The use of acuity-adaptable rooms can also substantially reduce possible sources (such as transfers, delays, communication discontinuities among staff, etc.) of medical error (Hendrich et al., 2002, 2004). Reducing Patient falls This is an important issue not only because of the physical injuries sustained but also due to the adverse psychological effects on patients and lengthened stays in hospital. The problem particularly affects the elderly. May 2011 Page 7 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

8 There does not appear to be conclusive evidence linking environmental interventions with patient falls (Chang et al., 2004). Studies have sought to identify the design issues that might have contributed to falls (such as the placement of doorways, handrails and toilets), but no studies have compared different design options to determine the independent impact of a single design factor on the incidence of falls. One study has provided some promising findings, suggesting that decentralised nurse stations can reduce falls (Hendrich et al., 2002, 2004), but more research is needed to confirm these findings and to identify all the variables involved. Several studies have clearly shown that despite a popular misconception, bedrails do not reduce the rate of falls and can actually increase their severity, indicating that not all EBD interventions are intuitive. Reducing pain Mounting scientific evidence suggests that exposing patients to nature can alleviate pain (see, for example, Malenbaum et al., 2008; Ulrich et al., 2006). Additionally, limited research indicates that patients experience less pain when exposed to higher levels of daylight (Walch et al., 2005). Design measures aimed at reducing pain therefore should incorporate large windows so that patients can look out onto sunny nature spaces. Research also supports displaying visual art where pain is experienced. Furthermore, patients should not be placed in rooms that lack nature distraction and contain environmental stressors such as noise. Reducing patient stress The Ulrich report suggests that, as with pain, psychological and physiological stress can be reduced by real or simulated views of nature. Gardens in hospitals are particularly beneficial, as is representational (but not abstract) art. Noise is a pervasive stressor and a high priority should be placed on creating much quieter hospital environments by making use of high-performance sound-absorbing materials on ceilings and walls. A key factor in improving patients sleep is the provision of singlebed rooms. Reducing patient depression The Ulrich report puts forward that a large body of rigorous evidence indicates that exposure to bright daylight (or bright artificial light) is effective in reducing depression and patients with depression can have faster recovery times if they are assigned to sunnier rooms (Golden at al., 2005). Consequently, hospitals should be designed and sited to ensure that depressed patients have abundant natural light and larger windows should also be beneficial. Reducing length of stay The review states that there is limited evidence available on this issue, although a few studies point to the positive impact of light and views of nature. The review also made the following points about the impact of EBD on hospital staff. May 2011 Page 8 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

9 Improving staff outcomes Ulrich suggests that the most serious problem facing hospital staff is the large number who experience back injuries attributable to patient handling. Ceiling lifts have been identified most consistently as the solution, although it is important that their physical implementation is accompanied by a programme to educate staff. It is thought that staff suffering from stress might benefit from views on nature, bright daylight and reduced noise in much the same way as patients. A summary of the relationships between design factors and healthcare outcomes as defined by Ulrich et al. (2008) is shown in Table 1. Researchers believe that adopting an EBD approach within healthcare can provide an organisation with benefits other than patient-related outcomes and staff satisfaction. From a budgetary and organisational standpoint, Hamilton and Watkins (2009) argue that EBD can induce improvements in efficiency and financial performance through: Confidence in research grounded concepts: defensible designs and budgets, improved document quality, credible evidence of project performance and strength of client recommendations. Improved profitability/efficiency: useful feedback data on completed projects, better quality documents, improved project management and efficient internal design process. Acquisition of new work: data on performance of completed projects, credible claims during business development, visibility in the marketplace (speaking, writing), expertise in the field and strength of reputation. May 2011 Page 9 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

10 Single-bed rooms Access to Daylight Appropriate lighting Views of nature Family zone in patient rooms Carpeting Noise-reducing finishes Ceiling lifts Nursing floor layout Decentralised supplies Acuity-adaptable rooms Reduced HAIs ** Reduced medical errors * * * * Reduced patient falls * * * * * * Reduced pain * * ** * Improved patient sleep ** * * * Reduced patient stress * * * ** * ** Reduced depression ** ** * * Reduced length of stay * * * * Improved privacy ** * * Improved communication ** * * Improved social support * * * Increased patient satisfaction ** * * * * * * Decreased staff injuries ** * Decreased staff stress * * * * * Increased staff effectiveness * * * * * * Increased staff satisfaction * * * * * * indicates that a relationship between the specific design factor and healthcare outcome was indicated, directly or indirectly, by empirical studies reviewed in this report. ** indicates that there is especially strong evidence (converging findings from multiple rigorous studies) indicating that a design intervention improves a healthcare outcome. Table 1: Relationships between design factors and healthcare outcomes. While Ulrich et al. (2008) prioritised patient safety issues in their examination of the available literature, it is clear to most observers that there is an interdependent relationship between EBD and the concept of patient-centred care, which has also been the focus of a considerable amount of research. Patient-centred care (PCC) is defined by Hurtado et al. (2001) as healthcare that establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patients wants, needs and preferences and that patients have the education and support they need to make decisions and participate in their own care. However, in responding to the full needs of patients and their families, PCC not only redefines the relationships in healthcare and shapes policies and programmes but also influences the design of facilities and staff interactions (Institute for Patient- and Family-Centered Care, n.d.; Planetree, 2009). In fact, many of the design interventions which tend to result from patient-centred strategies such as single-bed rooms, access to daylight, May 2011 Page 10 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

11 views of nature, etc., are identical to those engendered by EBD. Becker and Carthey (2007) construe EBD to be a subset of wider PCC activity; specifically, these authors state that evidence-based design is viewed as the means of delivering design solutions that improve patient-centered care. Hamilton (2004) concludes that EBD in healthcare has the following attributes: appeals to physicians who practice based on medical evidence; gives patients and families higher-quality experiences; appeals to business-minded administrators by reducing costs and improving organisational effectiveness; helps hospital boards as they seek evidence to justify costly decisions; benefits the public, consumer groups and those paying the bills as they seek effective, lower-cost health care. Berwick (as cited in Sadler et al., 2008) also states that one of the happy sides to this idea of evidence-based design is that, unlike some calls for changes in healthcare, it really thoroughly unites the interests and life experience of the work force in healthcare with that of the patient (p. 3). When implementing EBD alterations in light of research findings and the perceived need to address patient-centred issues, certain organisations have opted for radical changes, such as re-designing or clustering certain departments, while others focused more on internal aspects such as décor. Some of the common EBD developments that have been made in healthcare include (The Center for Health Design, 2008): Size, setup and décor of patient rooms: Rooms are larger to accommodate family and friends and intimidating equipment is hidden. Décor and lighting is home-like and sensitive to patient conditions and moods. A patient server with a bedside computer terminal keeps needed supplies in each room, enables caregivers to respond more quickly and eliminates the need for a central storage area. Hallways are quieter and uncluttered, enabling patients to gain more rest and heal faster; Refining the central nursing station: By moving supplies, caregivers and records closer to patients, centralised nursing stations can be reduced in size. Work areas for staff are decentralised and located in pods while a central reception area handles admissions. Relaxing areas are provided for caregivers to take breaks and confer with colleagues; Movement of services, not patients: Where nursing stations have been decentralised, the extra space available could serve as satellite stations for frequent services such as physical therapy, radiology or a pharmacy. Other available space can be transformed into patient libraries, activity rooms and dining areas. Examples of EBD interventions for existing and new healthcare facilities in addition to a checklist for providing an optimal healing environment are provided in Appendix 1. May 2011 Page 11 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

12 The Evidence-based design process EBD must be holistically integrated within the different stages of building design, thereby requiring the combined effort and collaboration of a team comprising decisionmakers, planners, architects, contractors, healthcare staff and possibly also patient and community representatives. According to Zimring et al. (2008), EBD infuses principles, goals and expected outcomes throughout all steps of planning, designing and operating buildings (p. 2). It reflects an organisation s ability to change and a willingness to measure and confront the results of measurement. As such, EBD s procedures and philosophy should be included in an organisation s strategic plans and policies and should be integrated within its vision, specifying the organisation s commitment to use EBD research during future plans and decision-making (The Center for Health Design, 2009b). Healthcare decision-makers in particular, should always ask themselves: How will the proposed project incorporate all relevant and proven evidence-based design innovations to optimise patient safety, quality and satisfaction, as well as work-force safety, satisfaction, productivity and energy efficiency? (Sadler et al., 2008, p. 7). The course of action taken to implement EBD differs somewhat depending on the organisation in question, with The Center for Health Design (2008) breaking it down into eight straightforward steps: define evidence-based goals and objectives; find sources for relevant evidence; critically interpret relevant evidence; create and innovate evidence-based design concepts; develop a hypothesis; collect baseline performance measures; monitor implementation of design and construction; measure post-occupancy performance results. Hamilton and Watkins (2009) define the following nine stages: establish the client s goals; list the practitioner s project goals; identify the key design issues; convert key design issues into research questions; collect information & gather evidence relevant to the questions; critically interpret the evidence; develop concepts to achieve desired design outcomes; hypothesise predicted outcomes linked to the EBD concepts; select measures suited to the questions posed by the hypothesis. May 2011 Page 12 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

13 On the other hand, Cama (2009) specifies only four phases to guide EBD, although each step includes several activities. These are: Gather Qualitative and Quantitative Intelligence involves the methodological gathering of past research to inform project goals and guidelines. An interdisciplinary team learns the organisation s culture, objectives, norms and principles and determines whether current research can provide the best solution, or whether innovation is required. Possible solutions are researched further to determine the lessons other organisations have learned while implementing them and how they can be improved. A dialogue begins on how to structure the research project in a way that will benefit all involved; Map Strategic, Cultural and Research Goals to analyse the body of knowledge, a graphic map can be used to simplify information, illustrate goals and develop a vision. Visioning activities enable certain topics to be explored and expanded, thereby emerging intricate details. A research agenda should be discussed and developed around the project guidelines, strategic initiatives and desired organisation transformations and innovations. The agenda should also consider how the brand connects to the organisation s promise to patients, community and staff; Hypothesise Outcomes, Innovate and Implement Translational Design research project is activated by a clear hypothesis that provides direction, specificity and focus. Team engages in a design intervention as a means to an end rather than simply a solution and begins to hypothesise outcomes that can be tied to new and different problem-solving approaches. The team can either continue moving forward to prove that a known outcome can be successful in their organisation s conditions, or they can introduce a new concept to prove or disprove a hypothesis. Design approaches are tested at the bedside for safety and effectiveness and revised where necessary to conform to the organisation s culture and operational model; Measure and share outcomes hypothesised outcomes are evaluated and results are reported at conferences or through peer review to enable other academic partners to construct an argument for or against the design intervention. Lastly, Harris et al. (2008), rather than presenting exact steps, describe key factors that should be included within the procedure as follows: the deliberate and critical use of evidence that has been collected systematically throughout the design process, using a variety of data and data-collection methodologies, to gain an understanding of how design decisions are likely to affect performance outcomes and project-specific goals; a multidisciplinary design team that can examine a project from different perspectives; considering the relevance of evidence collected as part of a formal, systematic research phase, as well as that derived from professional experience, site visits and discussions with content experts, medical staff and administrators; hypothesising early in the design phase about the potential effects of key design decisions on outcomes; identifying and measuring or tracking outcomes to assess performance. May 2011 Page 13 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

14 The factors common to the various interpretations of EBD detailed above indicate that the design process can be encapsulated thus: define goals and objectives; critically interpret available evidence; develop design concepts to achieve hypothesised performance outcomes; following implementation (ideally on a pilot basis), outcomes are measured and shared with other groups. With regard to the EBD team, The Center for Health Design (2009b) states that executive level leaders are a particularly essential component due to their power over financial decisions and their ability to drive institutional and cultural change. This sentiment is echoed by Zimring et al. (2008), who state that none of the projects they studied would have succeeded without the central involvement of the organisations innovative CEOs who were able to focus the energy and efforts of the EBD team. In addition to executive leadership, The Center for Health Design (2009b) states that individuals from all levels of an organisation should be involved in EBD to ensure it receives financial, cultural, technological and administrative support. In particular, frontline managers and staff can stimulate and drive new ideas and provide a daily use perspective, while patients and community representatives can contribute the user viewpoint to design decisions. Strategies for implementing evidence-based design In Zimring et al. s 2008 study, which analysed successful EBD projects led by innovative CEOs, ten useful strategies for implementing EBD were identified. According to the authors, these enable EBD to be implemented in a consistent and progressive manner and help move the theory beyond senior management ideas into everyday facility decisions. The strategies recognised were: Start with problems: Identify the problems the project is trying to solve and for which the facility design plays an important role. These may include technology upgrades, an expansion of services, an increase in patient safety, an improvement in employee efficiency or the replacement of ageing infrastructure; Use an integrated multidisciplinary approach with consistent senior involvement that overcomes silo thinking by developing institution-wide perspectives and goals. This includes identifying the innovations that can transform healthcare and the staff who can lead the transformation; Maintain a patient-and-family-centred approach. Patients and family representatives should be included in decision-making groups and the patient and family experience should be defined through factors such as reduced wait times, reduced walking distance, better lit settings and an increased sense of control; Focus on financial operating impacts. Successful project teams focus on the cost-effectiveness of design decisions over time, rather than the initial capital costs. Innovative leaders focus on the relationship between factors such as pay for performance trends and customer satisfaction scores that will further strengthen the business case; May 2011 Page 14 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

15 Take a broad and disciplined approach to participation and criteria management. Successful projects have been deliberate about gathering all criteria upfront through a broad and active participatory stage that includes all major stakeholder groups; Establish quantitative criteria linked to incentives. People are more likely to change their behaviour if they have measurable goals that are linked to incentives; Use strategic partnerships to accelerate innovation. Hospitals are often very significant customers and they can use this leverage to create innovative new products or services that better fit their needs and provide a competitive edge; Support and demand simulation and testing throughout. Simulation can take place through assuming the patient s perspective, carrying out lean design, creating lighting and energy models or using computer visualisation. Testing can occur through completing physical mock-ups or using permanent computer-based simulation and innovation centres; Use a lifecycle perspective. A building s lifecycle includes four phases: preplanning activities, project-specific activities, construction and commissioning and sustainment. Successful projects use the facility as a strategic tool at each step in a building s lifecycle and explore the lifecycle return on investment of design strategies as they impact safety and workforce outcomes; Overcommunicate. In successful projects, CEOs have had to communicate more than anticipated and explain desired outcomes through a number of methods to ensure all team members understand the procedure. Employees should be kept up to date and involved in all steps through a variety of activities such as meetings, newsletters and web cams. The Evidence in evidence-based design As stated previously, a key component of EBD is the gathering of quality research and its application to the project at hand (The Center for Health Design, 2008). Edelstein (as cited in The Center for Health Design, 2009a), states that evidence-based design looks to the inclusion of the best available evidence that uses rigorous methods from the broadest possible range of sources. It therefore behoves designers to acquire and incorporate into practice the skills required to search, access and interpret information from currently available sources. It must be noted that the evidence of one outcome in a certain situation may not always be transferable and a particular design may not work in all facilities (The Center for Health Design, 2008). Since different environments have varied constraints and requirements, builders, designers and healthcare decision-makers must adapt the research and delivery to fit their specific setting and building (Barach, as cited in Harris et al., 2008). Particular notice must also be paid to the context in which pieces of evidence are derived, with Ulrich et al. (as cited in The Center for Health Design, 2008) stating that randomised controlled trials or experiments are considered the strongest research design for creating valid and relevant empirical evidence within the medical field. To ensure evidence is valid and credible, the research phase should be methodological and, according to The Center for Health Design (2009a), generally incorporate the following steps, cycling back to the first step when additional research topics are found: May 2011 Page 15 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

16 research question; literature review; hypothesis; research planning; pilot study; data collection; data analysis; report; future research. Evidence can be gathered through qualitative or quantitative approaches (or any appropriate combination), incorporating questionnaires, observations, post-occupancy evaluations, surveys, rating scales, interviews and focus groups. An important component of the procedure involves analysing evidence to ensure its credibility and validity; this can be determined through factors such as its publishing date, study location, relevance to the project in question, research methods used, source of information, peer-reviewed evaluations, origin of document and publisher. Where insufficient credible evidence exists or, alternatively, to contribute to the knowledge base on a specific topic, organisations can create new evidence through designing their own relevant research studies (The Center for Health Design, 2009a). To manage the evidence gathered, a computer-based programme such as IDEA (Inspiring Design Excellence and Achievements) can be used to present and store examples and recommendations. Two other similar programmes that are currently in use with the NHS include AEDET (Achieving Excellence Design Evaluation Toolkit) and ASPECT (A Staff and Patient Environment Calibration Tool). Both of these programmes evaluate ideas and designs based on concepts such as character and innovation, performance, construction, space, staff and patient environment, nature and outdoors, views, interior appearance and comfort and control (Codinhoto et al., 2008). More detailed and step-by-step information on the gathering and analysis of evidence within EBD can be seen in Evidence-Based Design Accreditation and Certification (EDAC) programme Study Guide series (namely, The Center for Health Design, 2008, 2009a, 2009b). In addition, A Practitioner s Guide to Evidence-Based Design by Harris et al. (2008) provides an excellent source of answers to the many questions that may arise during the EBD planning stage. The cost of evidence-based design In the short-term at least, organisations will probably incur monetary costs by adopting an EBD approach. Whitehead et al. (n.d.) state that the healthcare design interventions can be either dominant in economic terms (i.e., they produce additional benefits at zero or reduced cost) or they can produce additional benefits at an added cost, thereby requiring a comparison of cost-effectiveness. However, rather than focusing on the initial costs, embracing EBD entails treating a building and its design May 2011 Page 16 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

17 improvements as a valuable asset, since a well-designed physical environment can help organisations avoid unnecessary costs (Sadler et al., 2008). In a study completed by The Center for Health Design regarding a hypothetical EBD hospital, an analysis of operating cost savings resulting from factors such as reduced infections, the elimination of patient transfers, fewer patient falls, lower drug costs and a lower employee turnover rate, indicated that with effective management and monitoring, the financial benefits of EBD alterations can continue for many years, thereby making them a sound long-term investment (Sadler et al., 2008). According to Sadler et al. (as cited in The Centre for Health Design, 2009a), incorporating the best design innovations can add to capital costs initially. However, many evidence-based design features do not cost more. Many people do not realise that these features can significantly reduce operational costs over the life of the project, more than offsetting initial incremental capital costs (p. 3). Therefore, through an investment perspective, the savings that will arise can be documented and used to convince healthcare decision-makers that EBD modifications are worthwhile and cost-effective (Sadler et al., 2008). It should be noted that in order to be cost-effective, EBD must be supported by a cultural transformation and changes in clinical procedures within a healthcare organisation (Zimring et al., 2008). For instance, building a single-patient room that incorporates extra sleeping accommodation is only useful if an organisation s staff culture and visiting hours encourage family participation and inclusion (Hamilton et al., 2008). These authors further state that a comprehensive, compatible marriage in the planning and implementation of evidence-based design and cultural initiatives is not only an opportunity, but can be a risk if left unattended (p. 5). Similarly, no physical EBD development is likely to produce dramatic results independently. For instance, the installation of ceiling lifts will not autonomously reduce caregiver back injuries. However, this intervention can be highly effective when coupled with a comprehensive no lifts education and standards programme. EBD interventions therefore should be part of an integrated set of changes that in combination will enable improvement (Sadler et al., 2009). Observations from the case studies Twelve case studies were reviewed to determine how various organisations have approached EBD, the lessons learned during the experience and the benefits gained as a result of the design interventions. A summary of these case studies can be seen in Appendix 2. To develop a well-rounded perspective, the case studies were derived from a number of sources and represent organisations located in the United States, England and Scotland. It was found that the organisations implemented broadly similar EBD interventions which can be supported by the literature. The examples used focus on improving aspects such as patient satisfaction, work-life quality for staff, noise levels and patient safety (Sadler et al., 2008). In general, these interventions introduced: hotel-like features that are warm, inviting, open and calming and incorporate good airflow and natural light and, wherever clinical considerations permit, wood designs and carpeting; May 2011 Page 17 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

18 hotel-like or home-like private rooms that are well-planned, flexible and can adapt to changes in a patient s condition. Rooms accommodate and encourage family involvement and include a private bathroom and hand-washing facilities for staff; nurse areas are decentralised and include small workstations in or near patient rooms to ensure patients can always be monitored; increased and welcoming signposting and access. As a result of these design features, all of the case study organisations gained important benefits, which included factors such as increased work efficiency, effectiveness and productivity, staff, patient and visitor satisfaction, staff and patient safety, patient sleep and ability to recruit and retain staff. There were also decreases in the numbers of patient transfers and trouble incidents, the avoidance of preventative costs, quick returns on investment and a series of organisational and architectural awards. These overall findings support the literature (Cama, 2006; The Center for Health Design, 2008; Ulrich et al., 2008; Hamilton & Watkins, 2009) indicating that the benefits of applying EBD features within a healthcare organisation are generally well worthwhile, provided the resources need to support the changes are available. It is also apparent from reviewing the case studies that before making evidence-based alterations each organisation determined which values they were aiming to achieve through the improvements. For instance, Dublin Methodist Hospital and Parrish Medical Center wanted to establish an overall healing environment, while PeaceHealth Organisation sought to decrease staff injuries and Maggie s Centre in London wanted a building that would rise to the occasion, raise your spirits and be surprising and thought-provoking. This finding not only further strengthens that of the literature (The Center for Health Design, 2008) but also indicates that, to ensure the success of the EBD approach, organisations must have specific goals in mind. With regard to other findings, the case studies provided relatively little information on the procedures and strategies used to implement their EBD changes, the barriers organisations faced along the way or the lessons learned during the process. However, within the Provena Mercy Medical Center and Peace Health Organisation there was mention of the need for support in terms of cultural transformation and changes in established ways, which reinforces Zimring et al. s (2008) previous findings. May 2011 Page 18 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

19 Conclusions and recommendations Based on the findings of the case study review, it is evident that implementing EBD changes can result in valuable benefits for healthcare organisations. However, as stated in the literature and the case studies, it is important that as EBD modifications are implemented there is good communication with healthcare staff to ensure their acceptance. It is also important for organisations with these changes to view them as long-term investments that will ultimately yield the aforementioned benefits rather than focus on the initial costs of their implementation. Based on the information gathered in this literature review and the case study findings, it is recommended that should NHSScotland wish to pursue an EBD approach it progresses through the steps detailed below. However, it is important to re-iterate that design features may not always be transferable between different facilities or even regions. Thus, NHSScotland should consider the individual goals and needs of each specific healthcare facility before determining which adjustments to implement. As a result, the following list should be individualised as appropriate for each facility under consideration. Pre-evidence gathering phase Recommendation 1: Because the costs of implementing EBD modifications tend to be balanced through long-term savings such as decreased staff injuries, use of EBD is most appropriate for facilities that will be retained and used by the organisation well into the future. Therefore, it is recommended that current healthcare facilities should be categorised according to their anticipated lifespan and future use and any facilities that will be sold or demolished within the next few years disregarded. The remaining facilities should then be ranked according to their need for EDB improvements, which would benefit most from the changes and in which investment would prove to be most cost-effective. In undertaking this exercise, consideration should be given to the issue that, while smaller facilities may need fewer and less costly alterations, larger hospitals coping with hundreds of thousands of patients each year may prove most cost-effective for EBD adjustments in the long run, due to a potentially quicker return on investment. Recommendation 2: For each facility that could benefit from EBD modifications, there should be communication with the facility s staff and managers to determine individual goals and where improvements should take place. These may include increasing patient safety, decreasing patient HAIs, increasing staff satisfaction or creating a more home-like and healing environment. In developing these aims, NHSScotland should determine which difficulties currently exist that prevent them being achieved. Following this exercise, a series of research questions will consequently arise which will guide the evidence-gathering phase. Evidence-gathering phase Recommendation 3: Using these questions, those carrying out the review should conduct thorough research to gather and analyse evidence and information that could be of assistance in providing informed answers and thereby support the possible future design modifications. Should no evidence exist, however, reviewers should consider May 2011 Page 19 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

20 whether they are willing to create and share new evidence through a transparent trialand-error procedure. Recommendation 4: Using the information gained from the evidence, reviewers should develop design concepts that could achieve their desired outcomes. Several hypotheses should then be developed to test the anticipated approaches and results. Recommendation 5: In order to determine whether improvements are made and goals achieved, baseline performance measures for the facility related to the topics concerned will need to be collected first. This information could be gained through research methods such as questionnaires, surveys or focus groups and could cover topics such as patients attitudes and satisfaction, staff motivation or patient hospitalacquired infection rates. Recommendation 6: To avoid unnecessary disruption, the hypotheses should undergo pilot-testing through the use of mock facilities. Patients, staff, families and healthcare management can then provide feedback and revisions to the design made as necessary before it is re-tested. To prepare staff for the disruption and changes, an education and support programme should be developed that will accompany the improvements and enable staff to familiarise themselves with forthcoming developments. Post evidence-gathering phase Recommendation 7: Following successful pilot tests and the re-education of staff, EBD modifications should be implemented, ensuring programmes are kept in place to support and educate staff on the new methods. Recommendation 8: Lastly, after the changes have been effected and the facility is re-occupied as normal, the design s success level based on the baseline monitoring data collected should be assessed. After gathering this new information, the lessons learned, benefits gained and modifications made during the exercise should be documented and, if possible, shared with other organisations through peer-reviewed journals. May 2011 Page 20 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

21 References Anjali, J., Fritz, L. (2006). Ceiling lifts reduce patient-handling injuries. Healthcare Design, March Retrieved Mar 25, 2011 from 81EA3C0C3CCE4943&nm=Articles&type=Publishing&mod=Publications%3A%3AArticl e&mid=8f3a f18be895f87f791&tier=4&id=36dec4b1fae64e77a2 CE07A13E5270C2 BDP. (2010). Royal Alexandra Children s Hospital. Retrieved Mar 25, 2011 from Hospital/?category=21&parentpageid=37 Building Better Healthcare (n.d.). Admissable evidence. (sic) Retrieved on Mar 23, 2011 from Cama, R. (2006). The Opportunity is Now. In S. O. Marberry (Eds.), Improving Healthcare with Better Building Design (1-14). The Foundation of the American College of Healthcare Executives, Chicago. Cama, R. (2009). Evidence-Based Healthcare Design. John Wiley and Sons, New Jersey. Cameron, L. (2009). Scots hospital superbugs cost 183m a year. Retrieved March 3, 2011 from The Center for Health Design. (2008). Study Guide 1: An Introduction to Evidencebased Design, Exploring Healthcare and Design. The Center for Health Design, California. The Center for Health Design. (2009a). Study Guide 2: Building the Evidence Base, Understanding Research in Healthcare Design. The Center for Health Design, California. The Center for Health Design. (2009b). Study Guide 3: Integrating Evidence-Based Design, Practicing the Healthcare Design Process. The Center for Health Design, California. The Center for Health Design. (2010). The Pebble Project. Retrieved Mar 25, 2011 from Chang, J.T., Morton, S.C., Rubinstein, L.Z., Mojica, W.A. (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. Clark, P.A., Malone, M.P. (2006). What Patients Want: Designing and Delivery Health Services that Respect Personhood. In S. O. Marberry (Eds.), Improving Healthcare with Better Building Design (15-36). The Foundation of the American College of Healthcare Executives, Chicago. May 2011 Page 21 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

22 Codinhoto, R., Tzortzopoulos, P., Kagioglou, M.,Aouad, G., Cooper, R. (2008). The Effects of the Built Environment on Health Outcomes. Health and Care Infrastructure Research and Innovation Centre, London. Commission for Architecture and the Built Environment. (2010). Case Studies. Retrieved March 22, 2010 from Design Council. (2009). Birmingham Heartlands Hospital: Designing out Crime Case Study. Retrieved March 3, 2011 from E-Architect. (2010) Royal Alexandra Hospital: Sussex Building. Retrieved Feb 23, 2010 from Edwards, R. (2008). A New Model for Hospital Design Rises in an Ohio Cornfield: Dublin Methodist merges beauty and brains to create a high-quality, patient-friendly facility. Hospital and Healthcare Networks. Retrieved March 9, 2010 from data/07jul2008/0807hhn_fea_architecture&domain=hhnmag Ethicon. (2008). SSI Symposium Summary Report. Retrieved Mar 1, 2010 from pdf Farrow, T., VanderKaay, S. (2009). Design Quality Standards: Intangibles that bring hospitals to life. World Health Design, October Ferlie, E., Dopson, S., Fitzgerald, L., Locock, L. (2009). Renewing Policy to Support Evidence-Based Health Care. Public Administration, 84, Golden, R.N., Gaynes, B.N., Ekstrom, R.D., Hamer, R.M., Jacobsen, F.M., Suppes, T., et al. (2005). The efficacy of of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 162(4), Hamilton, D. K. (2004). Four Levels of Evidence-Based Practice. Retrieved Mar 25, 2011 from Hamilton, D. K., Orr, R. D., Raboin, W. E. (2008). Healthcare Leadership White Paper Series 2 of 5: Culture Change and Facility Design: A Model for Joint Optimisation. Retrieved Mar 25, 2011 from Hamilton, D. K., Watkins, D. H. (2009). Evidence-Based Design: Competitive Advantage for all Practices. Retrieved Feb 3, 2010 from Harris, D., Joseph, A., Becker, F., Hamilton, D. K., McCuskey Shepley, M., Zimring, C. (2008). A Practitioner s Guide to Evidence-Based Design. The Center for Health Design, California: May 2011 Page 22 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

23 Health Protection Scotland. (2010). The Annual Surveillance of Healthcare Associated Infection Report January December Retrieved April 12, 2010 from Health Grades. (2010). Bronson Methodist Hospital. Retrieved Mar 22, 2010 from Hendrich, A., Fay, J., Sorrells, A. (2002). Courage to Heal: Comprehensive Cardiac Critical Care. Healthcare Design, September Retrieved March 22, 2010 from ng&mod=publications%3a%3aarticle&mid=8f3a f18be895f87f791& tier=4&id= c3f fab e8 Hendrich, A., Fay, J., Sorrells, A. (2004). Effects of acuity-adaptable rooms on flow of patients and delivery of care. American Journal of Critical Care, 13(1), Hendrich, A., Chow, M. (2008). Healthcare Leadership White Paper Series 4 of 5: Maximising the Impact of Nursing Care Quality: A Closer Look at the Hospital Work Environment and the Nurse s Impact on Patient-Care Quality. Retrieved Mar 25, 2011 from Hurtado, M.P., Swift, E.K. and Corrigan, J.M., eds. (2001). Envisioning the National Healthcare Quality Report. National Academy Press, Washington DC. Available online retrieved Mar 24, 2011 from Institute for Patient- and Family-Centered Care. (n.d.). What is patient- and familycentered health care? Retrieved Feb 27, 2011 from Joseph, A. (2006). Health Promotion by Design in Long-Term Care Settings. The Center for Health Design. Research Summary, August Retrieved Mar 25, 2011 from Joseph, A. (2008). Hospitals That Heal. Hospital Design for the 21 st century. Asian Hospital and Healthcare Management. Retrieved Mar 25, 2011 from Maggie s Cancer Caring Centres. (2009). Maggie s London. Retrieved Mar 2, 2010 from Maggies Cancer Caring Centres. (2010). Welcome to Maggie s Dundee. Retrieved Mar 2, 2010 from Malenbaum, S., Keefe, F.J., Wiiliams, A.C., Ulrich, R. and Somers, T.J. (2008). Pain in its environmental context: Implications for designing environments to enhance pain control. Pain, 134, Malone, E., Mann-Dooks, J., Strauss J. (2007). Evidence-based Design: Application in the MHS. Retrieved Mar 25, 2011 from May 2011 Page 23 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

24 Mare, G., Walters, S. (2007). Dublin Methodist Hospital: Applying evidence-based design in a race to revolutionize healthcare. Hospitals and Healthcare Networks, March Retrieved Mar 10, 2010 from 81EA3C0C3CCE4943&nm=Articles&type=Publishing&mod=Publications%3A%3AArticl e&mid=8f3a f18be895f87f791&tier=4&id=6398e71cc89f E7A633E68D8F Planetree (2009). Patients as Experts, Patients as Partners: Integrating the Patient and Family into Hospital Operations. Retrieved Mar 25, 2011 from 0with%20Patients%20and%20Families2009.pdf Roberts, G., Guenther, R. (2006). Environmentally Responsible Hospitals. In S. O. Marberry (Eds.), Improving Healthcare with Better Building Design (81-108). The Foundation of the American College of Healthcare Executives, Chicago. Rollins, J. (2004). Evidence-based hospital design improves health care outcomes for patients, families, and staff. Paediatric Nursing, July-August Retrieved Feb 9, 2010 from Sadler, B. L., DuBose, J. R., Malone, E. B., Zimring, C. M. (2008). Healthcare Leadership White Paper Series 1 of 5: The Business Case for Building Better Hospitals through Evidence-Based Design. Retrieved Mar 25, 2011 from Sadler, B.L., Joseph, A., Keller, A., Rostenburg, B. (2009). Using Evidence-Based Environmental Design to Enhance Safety and Quality. Institute for Healthcare Improvement, Cambridge, Massachusetts. Stevenson, F., Humphris, G., Howells, L. (2010). Post Occupancy Evaluation: Promoting Wellbeing in Palliative Care. Retrieved Mar 25, 2011 from Ulrich, R.S., Zimring, C., Quan, X., Joseph, A. (2006). The Environment s Impact on Stress. In S. O. Marberry (Eds.), Improving Healthcare with Better Building Design (37-61), Health Adminstration Press, Chicago. Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H., Choi, Y., Quan, X., Joseph, A. (2008). Healthcare Leadership White Paper Series 5 of 5: A Review of the Research Literature on Evidence-Based Healthcare Design. Retrieved Mar 25, 2011 from Walch, J.M., Rabin, B.S., Day, R., Williams, J.N., Choi, K., Kang, J.D. (2005). The effect of sunlight on post-operative analgesic medication usage: A prospective study of patients undergoing spinal surgery. Psychosomatic Medicine, 67, Whitehead, S., Bending, M., Lowson, K., Saxby, R., Duffy, S. (n.d.) Cost-Effectiveness of Hospital Design: Options to Improve Patient Safety and Wellbeing: Systematic May 2011 Page 24 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

25 Literature Review of Operating Theatres. University of York: York Health Economics Consortium. Wickens, I. (1994). Improving Hospital Design, A Report on the King s Fund Hospital Design Competition for King Edward s Hospital Fund, London. Zimring, C. M., Augenbroe, G. L., Malone, E. B., Sadler, B. L. (2008). Healthcare Leadership White Paper Series 3 of 5: Implementing Healthcare Excellence: The Vital Role of the CEO in Evidence-Based Design. Retrieved Mar 25, 2011 from May 2011 Page 25 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

26 Appendix 1. Additional information Priority design recommendations Source: Sadler et al. (2008) Design Interventions Install hand-washing dispensers at each bedside and in all high patient volume areas. Where structurally feasible, install HEPA filters in areas housing immunosuppressed patients. Where feasible, install ceiling-mounted lifts. Conduct a noise audit and implement a noise-reduction plan. Install high-performance soundabsorbing ceiling tiles. Use music as a positive distraction during procedures. Use artwork and virtual-reality images to provide positive distractions Improve wayfinding through enhanced signage. Quality and Business-Case Benefits Reduced infections. Reduced airborne-caused infections. Reduced staff back injuries. Reduced patient and staff stress, reduced patient sleep deprivation, increased patient satisfaction. Reduced patient and staff stress, reduced patient sleep deprivation, increased patient satisfaction. Reduced patient stress, reduced patient pain and medication use. Reduced patient and staff stress, reduced patient pain and medication use. Reduced staff time spent giving directions, reduced patient and family stress. Table 2: Design Interventions Applicable To All Hospitals May 2011 Page 26 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

27 Design Interventions 1 Build single-patient rooms. 2 Provide adequate space for families to stay overnight in patient rooms. 3 Build acuity-adaptable rooms Build larger patient bathrooms with double-door access. Install HEPA filtration throughout patient-care areas. Install hand-washing dispensers at each bedside and in all high patient-volume areas. Install ceiling-mounted lifts in majority of patient rooms. Meet established noise-level standards throughout the facility. Use music as a positive distraction during procedures. Provide access to natural light in patient and staff areas. Use artwork and virtual-reality images to provide positive distractions. 12 Build decentralised nursing stations. 13 Include effective wayfinding systems. Quality and Business-Case Benefits Reduced infections, increased privacy, increased functional capacity, increased patient satisfaction. Increased patient and family satisfaction, reduced patient and family stress. Reduced intra-hospital transfers, reduced errors, increased patient satisfaction, reduced unproductive staff time. Reduced patient falls, reduced staff back injuries. Reduced airborne-caused infections. Reduced infections. Reduced staff back injuries. Reduced patient and staff stress, reduced patient sleep deprivation, increased patient satisfaction. Reduced patient stress, reduced patient pain and medication use. Reduced patient anxiety and depression, reduced length of stay, increased staff satisfaction. Reduced patient and staff stress, reduced patient pain and medication use. Increased staff time spent on direct patient care. Reduced staff time spent giving directions, reduced patient and family stress. Table 3: Design Interventions Before Construction or Major Renovation May 2011 Page 27 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

28 Checklist for an optimal healing environment Environmental Design Element 1. Build private patient rooms 2. Provide adequate space for families to stay overnight in patient rooms 3. Install alcohol-based hand gel dispensers: In patient rooms In patient-care areas 4. Meet World Health Organisation recommended noise level standards: Perform noise audit Develop noise reduction plan (e.g., eliminate audible paging) Implement noise reduction plan 5. Optimise lighting in medication prep areas 6. Minimise unnecessary patient transfers (e.g., acuity-adaptable rooms) 7. Provide wider doors in patient bathrooms 8. Install optimal air filtration systems (i.e., protect immuno-suppressed patients) 9. Install ceiling-mounted patient lifts to reduce staff injuries: In patient rooms In patient-care areas 10.Install clear, effective wayfinding systems 11.Install positive distractions (to reduce patient anxiety): Music Art and interactive art Architectural features 12.Provide choices for patients: Control lighting Control privacy Control music and visual images Implemented Yes No Comments May 2011 Page 28 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

29 2. Summary of case studies Maggie s Centre, Dundee, Scotland Source: Stevenson et al. (2010); Maggie s Cancer Caring Centres (2010) The Dundee Maggie s Centre opened in 2003 to provide information and psychosocial support to people with cancer and their carers. The four goals of the organisation are to design facilities that: lower the stress level of a patient; provide psychological support; help patients navigate the information explosion on cancer; provide peaceful, restful and striking environments with an important place for art and gardens. Maggie s Centre prides itself on its healing environments and incorporates design features as a key factor in the promotion of wellbeing. The building lies mainly on one level with an open plan kitchen and dining area where visitors can socialise and gain support. There are also smaller rooms available for one-to-one sessions and a balcony that overlooks the valley, providing a relaxing and inspiring view. A new garden transforms the area between Maggie s Centre and the nearby hospital, creating a relaxing place for patients and visitors and emphasising stress reduction and healing. The garden incorporates a labyrinth which mirrors the quest for information and peace of mind and provides an area for contemplation, relaxation and amusement for visitors, children and families. There is an open area for outdoor events, a small garden for families and patients to chat and a mix of indigenous and ornamental plants that give colour and variation to the seasons. Much thought has been given to parking and lighting in the area, as well as the pathway that leads to the hospital from the centre. In a post-occupancy survey, the highest ratings were given by 70% of visitors to the building s overall design and by 82% in relation to outside views. In addition, 78% felt that the building met their needs either well or very well and 90% felt the building was comfortable overall. In general, the building design has achieved a very high user satisfaction rating and visitors perceive increased health and wellbeing from visiting the facility. The only minor complaints found with regards to the building s design include slight overheating and glare in the kitchen area. Dublin Methodist Hospital, Columbus, Ohio Source: Edwards (2008); Mare & Walters (2007) A non-profit 94-bed facility, Dublin Methodist Hospital was designed to provide a comforting and calming atmosphere and promote patient healing. During the planning phase, hospital administrators firmly followed EBD concepts and studied examples throughout the country before developing their own hypotheses. The project team was particularly interested in learning how innovative design could improve the quality of May 2011 Page 29 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

30 healthcare, attract patients, increase operational efficiency, recruit and retain staff and increase outside and corporate support. They also felt that EBD could improve the emotional and spiritual well being of users as well as worker productivity. The guidelines for the planning process included: creating a healing environment with a stress-reducing design; designing for maximum standardization; including a wide representation of stakeholders in the design process; creating a patient/family-centred environment that respects privacy and dignity; providing clear signposting and accessibility; designing to support a digital, wireless and paper-light system. In addition, the following core values were developed by the planning team, in order to guide the specific design interventions of the new building: care for patients medically, spiritually and emotionally; respect the family of our patients and staff; encourage and promote education for our staff, patients and community; promote a close-knit team approach to care. The building now boasts an open atrium with live trees, a three-storey high waterfall and greeters that escort patients to their destinations, rather than a central reception. Glass corridors between patient pavilions and the treatment areas enable large amounts of natural light and views to nature, while polished wood, soothing earthy colours and bamboo accents provide a homely and calm atmosphere. All patient rooms in the hospital are oversized, private, include sleeping areas for family members and are fully adaptable to adjust to patient progress. Mini nurse stations have also replaced the traditional central nursing area and enable staff to be closer to the rooms and patients. In an attempt to increase the speed of information transfer and reduce errors, the hospital is also paperless. Other design features include private consultation rooms, open eating areas, multipurpose alcoves and an education centre. Every design intervention now used can be supported through previously published research. The organisation s president states that the private rooms prevent infection and medical errors; patients recovering in rooms with natural sunlight use half as much pain medication as patients who are in an interior room. The Vocera wireless communication system and sound-muffling ceiling tiles help keep the hospital quiet, which has been shown to benefit the emotional well-being of both patients and staff (Edwards, 2008, p.1). Although there have been discussions about the need for such a luxurious facility, its president states that in the end, we re convinced that there is going to be a payback for all the technology in terms of clinical quality, patient safety and patient satisfaction, as well as cost effectiveness (Edwards, 2008, p. 1). Within 100 days of opening its doors, the hospital was already experiencing shorter than average stays and daily admissions of 25 to 30 patients. May 2011 Page 30 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

31 Parrish Medical Center, Titusville, Florida Source: The Center for Health Design (2010) Parrish Medical Center, a 210-bed facility, opened in November 2002 and was the first medical centre in the Southwest region to be designed and contracted using EBD principles to create a patient-healing environment. The planning team strongly believed that the environment plays an integral role in the healing of the mind, body and spirit and incorporated the design around The Center for Health Design s seven healing environment elements which are nature, colour, light, environment, security, wayfinding and culture. The new facility is technologically advanced, efficient, patient-sensitive and userfriendly and incorporates appealing design features such as access to natural light, improved airflow, a division between public and patient transport areas and home-like patient rooms. It also has weekly live music concerts in the atrium, room service, concierge service, in-room entertainment systems, humour therapy and therapy dogs. The planning team also worked hard to develop a healing culture to support this new environment and one that would reflect the values, beliefs and philosophies that the building represents. As a result of their efforts, Parrish was named America s #1 Healing Hospital by the Baptist Healing Trust, and was awarded the country s first Discovery Award from Starison and Healthcare Design Magazine, for their patient healing environment. The design is also popular with staff and through a survey of 734 employees, it was found that most feel the friendly design features positively impact their work life quality and help them to work more effectively. Staff turnover has also decreased from 20% in the old facility to only 13% in the new building. Breast Care Centre, St. Bartholomew s Hospital, London Source: Commission for Architecture and the Built Environment (2010) The Breast Care Centre at St. Bartholomew s Hospital is housed in a refurbished Grade 1 listed building, designed using the latest thinking on hospital design and infection control to put patients at ease and provide comfort and reassurance. In designing the building, consultation was sought from a variety of sources and committees, including former patients, as well as research visits to other cancer care centres in the US and the UK. Design interventions were also developed as mock ups to enable staff to provide feedback and to gain support for controversial features. The planning goal was to develop a 'multi-disciplinary one-stop breast clinic in a human and reassuring environment in which quality is key - in terms not only of the building fabric and finishes but of providing a patient-friendly service'. In particular, careful consideration was given to the patient pathway through the building which begins and ends in a peaceful square with a fountain, as well as the colour schemes and materials intended to develop a calm and comforting environment housing all breast cancer services under one roof. May 2011 Page 31 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

32 The facility s hotel-style waiting area now enables patients to chat with family and friends in a semi-private environment and the art programme helps to distract visitors from the anxieties that surround a visit to the centre. The centre also has counselling rooms, a separate exit to enable patients who have received bad news to leave without facing those in the waiting area, a boutique where patients can see and try clothing, wigs and prostheses in privacy, a resource centre and a conference centre. Through the refurbishment and design, the facility has now been transformed into a fully functional medical asset with a high level of staff satisfaction. The changes have enabled managers to recruit and retain staff more easily; visitor reactions have been extremely positive, providing comments such as the way it s laid out makes you think of a swish hotel and it goes beyond functional, it s beautiful. It s a different world from what we had before. PeaceHealth Organisation, Eugene, Oregon Source: The Center for Health Design (2010); Anjali & Fritz (2006) Back pain is a major problem for nurses and nurse aids and those who perform manual lifting and transferring activities are at a particularly high risk of injury. To reduce the incidence and severity of work-related musculoskeletal disorders, PeaceHealth conducted a pilot project on ceiling lifts, by installing them in the ICU and Neurology Units of its existing facility (while waiting for their new facility to be built). The ceiling lifts were chosen due to the ease with which they can be used, the minimal effort needed to manoeuvre them, the less space needed to store and operate them and their ability to lift heavier loads. The known benefits of these lifts also include: reduction in incidence and severity of injuries to medical staff; decrease in patient falls, skin tears and abrasions; increased patient comfort, security and dignity during transfers; promotion of patient mobility and independence; enhanced toileting outcomes and increase in continence; improved job satisfaction and staff efficiency and increased empowerment of nursing staff; enhanced regulatory compliance (it is expected that within five years, the Occupational Safety and Health Administration (OSHA) will have mandatory ergonomic standards for acute care much like long-term care); enhanced compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. As a result of the ceiling lifts, staff injuries from patient handling have been almost eliminated and the cost of patient handling injuries has decreased by 99%. PeaceHealth now plans to make all the rooms in the new facility lift ready, and they estimate that the $1.64 million cost will be paid back in approximately 2 years. May 2011 Page 32 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

33 It must be noted, however, that some staff at Peace Health resist using the ceiling lifts and therefore this type of project must be completed alongside a no manual lift policy as well as an education and reinforcement programme regarding the importance and benefits of ceiling lifts. Royal Alexandra Children s Hospital, Brighton Source: E-Architect (2010); BDP (2010) Constrained by the need to maximise space on a tight site, the new 100-bed Royal Alexandra Children s Hospital was built in 2007 to provide a calm environment that improves clinical outcomes and recovery times, a positive experience during testing and, ultimately, surroundings where children could heal and recuperate. Although the previous facility provided a progressive and innovative paediatric environment, a new hospital was needed to provide more regional and specialist expertise thereby enabling fewer children to have to travel to London or out of the country for treatment. The new hospital is one of only seven dedicated paediatric hospitals in the UK. Designed to feel unlike a hospital, it combines high quality materials with efficient procurement, economic and social value, good teamwork between client, designer and contractor, sound financial management and whole-life value for money and sustainability. The planning process included the active involvement of staff, patients and their families, as well as a Children s and Young Person s Board that continues to play an important role in the functioning of the hospital. The revolutionary boat-inspired hospital is buoyed by family values and has enabled many regional pediatric services to be centralised in one facility. Developed from a user- and children-centred perspective and based on clinical studies and previous evidence, the building encompasses single- and multiple-patient rooms with sea-views and family accommodation, child-scaled furniture and windows, large amounts of natural light due to a shallow floor, user-friendly environmental controls and lots of vibrant colours. The top floor houses a staff lounge, parent accommodation and children s play decks that are open to sea and sun. The main atrium binds all the levels together and creates a holistic feel that is noticeable by anyone entering or moving around the building. This main area serves as the outpatients reception and waiting area and encompasses a café and shop, which form the social hub of the hospital. As a result of their efforts in EBD, the Royal Alexandra Children s Hospital has developed widespread international recognition and has an average MRSA blood infection rate of only 1.3 for every 10,000 bed days. The hospital has also won the following awards: Civic Trust Award 2009; Prime Minister s Better Public Building Award 2008; IADH Health Care Design Project Award 2007; Building Better Healthcare Award 2007; May 2011 Page 33 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

34 Health Business Award St Alphonsus Regional Medical Center, Boise, Idaho Source: The Center for Health Design (2010) Saint Alphonsus Center, in consultation with the Center for Health Design, completed a major renovation project in October 2007, which culminated in the state-of-the-art Center for Advanced Healing. The Center now includes cutting edge medical technologies and treatments, EBD principles that are proven to increase healing rates and highly skilled staff that involve patients and families throughout the healing process. The patient facility includes private rooms, a 16-suite operating theatre, a new ICU and improved wayfinding and access. The new additions and renovations have been designed to improve patient health outcomes, privacy, comfort and safety. Specific changes include: new 32-bed Intensive Care Unit; new nine-story patient care tower built at a capacity for 32 beds per floor; private rooms that incorporate care zones for clinical staff and family members; Smart beds that help reduce staff injuries and enhance patient care; increased square footage for the operating rooms; new Kissler Family Library and Research Center; healing environments that take into account the benefits derived from a patient s view out the window to the colour and patterns on the wall; a new circulation route around the campus to improve access to the facilities and wayfinding. Although evaluations are still underway for this project, the Center completed a similar and smaller refurbishment using the same research methodology, and successfully achieved the following outcomes. noise levels were reduced by designing larger private rooms, adding carpet to hallways, fitting acoustical tiles on walls and ceilings and relocating machinery and nurse charting away from patients; average decibel rate per patient room was less than 51.7 db; quality of sleep improved from 4.9 to 7.3 (on a scale of 0-10); patient satisfaction scores improved during a three-month comparison period. May 2011 Page 34 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

35 Bronson Methodist Hospital, Kalamazoo, Missouri Source: The Center for Health Design (2010); Health Grades (2010) Bronson Methodist Hospital has been undergoing redevelopment since 1993 to create a state-of-the-art, accessible healthcare campus that includes inpatient and outpatient care and doctor offices in a patient-focused healing environment with 343 beds. In 2000, Bronson completed their medical office pavilion, in addition to an outpatient pavilion, inpatient pavilion and central garden atrium. The success of this project led Bronson to develop another freestanding inpatient pavilion using EBD principles in 2007 housing its birthing centre and neonatal intensive care unit. In designing the hospital, elements were incorporated that have been proven scientifically to improve healing, with space, light, colour and nature all playing an important role. The facility houses only private-patient rooms that are adaptable to the patient s condition they emphasise access to nature, patient empowerment and control and positive distractions. Rooms have light-filtering blinds and large-button phones within easy reach for patient use and patient wear has been upgraded to include robes, pajama pants and more comfortably fitting gowns. There is also a mix of rotating and permanent artwork and soothing music can be heard throughout the hospital. Plants and flowers are located in all public areas as well as the main garden atrium in the centre of the facility. Since their opening and as a result of their evidence-based design features, the following achievements have been realised: nursing turnover rates are down to 4.7%; occupancy rate has risen to 87%; overall patient satisfaction increased to 96.7%; private patient rooms have resulted in decreased patient transfers because of the elimination of conflicts among patients that necessitated moves and an increase in patient sleep quality; private rooms, location of sinks and air inflow design have also resulted in an 11% decline in overall nosocomial infection rates; market share has increased; employee satisfaction has improved; built environment survey found that private rooms made for a better patient experience and that it enables a higher quality of patient care; received the 2005 Malcolm Baldrige National Quality Award, the 2009/ 2010 Distinguished Hospital Award for Clinical Excellence, the 2009/2010 Outstanding Patient Experience Award, and the 2009/2010 Women s Health Excellence Award. Maggie s Centre, London, England Source: Commission for Architecture and the Built Environment (2010); Maggie s Cancer Caring Centres (2009) May 2011 Page 35 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

36 Maggie s Centre in London is a drop-in centre or open-house for people living with cancer and their family and friends. Set within a calm, landscaped area of a major hospital offering specialist oncology diagnosis and treatment, the centre is designed to provide a feel-good mood and a place that is inspiring and uplifting to users. During the design process, the following elements were developed as the main goals: entrance: obvious, welcoming, not intimidating; a welcome, sitting, information and library area, from which the rest of the building should be clear; there should be as much light as possible and views out to grass/trees and sky; you should be able to see where the kitchen area is (with a table to sit 12) as well as the sitting room and fireplace area (hearth and home); a large soundproofed room for relaxation groups and meetings; two smaller sitting/counselling rooms; office space for the head of the centre and deputy (easily seen from the welcome area to ensure constant eye contact between staff and entrance); a garden area easily accessible from the building but which is buffered from the wider urban context. Overall, the building was needed to rise to the occasion, raise your spirits and be surprising and thought-provoking. The resulting design blends traditions from a range of cultures, with Scandinavian colours and materials, a Japanese garden and a variety of artwork along the walls. It is felt that this celebration of colour and form are key components in offering hope and support to users and providing a sense of status and dignity. Within the sign-less building is an open-plan kitchen area and hearth where people can gather to talk and socialise. There are also several small, quiet rooms that can be used for workshops or meetings and a library and office area. The building incorporates balcony areas and a courtyard garden with over 80 trees which shields it from the noisy urban surroundings and reduces pollution levels. In addition, sustainability principles were followed during the building process, with timber from renewable sources, a strong emphasis on the natural circulation of light and air, highly effective insulation, the recycling of rainwater and easy-to-operate maintenance systems. As a result of its design, the centre won the Stirling prize for Architecture in 2009 and received 12,000 visitors in its first year of operation: a 63% increase on what was expected. Methodist Hospital/Clarian Health Partners, Indianapolis, Indiana Source: The Center for Health Design (2010); Hendrich et al. (2002) Clarian Health Partners opened a new 56-bed Cardiovascular Comprehensive Critical Care Unit at Methodist Hospital in During the planning process the team was May 2011 Page 36 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

37 aware of the aesthetic inadequacies and inconveniences in many existing hospital environments and were particularly challenged by the anticipated cost of patient transfers, the nursing shortage impacts, inefficient use of nursing time, an ageing population and emerging but disruptive technology. Using EBD principles and an analysis of existing hospital processes and functions, a plan was developed that eliminated waste and inefficiencies while not compromising on the time that patients spent with caregivers. The environment was primarily designed to promote healing and enable family involvement in the care process. Healing characteristics such as interior design, décor, lighting and patient control were important elements throughout the design phase. The resulting unit combines the former critical care unit and a step-down unit of medical care into a single nursing area. All patient rooms, which are private and have views of nature, are critical-care-ready and adaptable to different levels of patient care, thereby almost completely eliminating the need for patient transfers. Patients, as they improve, are also able to control their own temperature, privacy and lighting and can access educational tools through their televisions. The rooms cater to families, patients and caregivers and waiting areas are designed to provide a soothing atmosphere with aquariums, indoor gardens, lockers and kitchenettes. Nursing areas are also decentralised and equipment kept in corridors is hidden from view. Staff have their own lounges and bathroom/shower facilities. As a result of their design features, the hospital has realised the following achievements: patient falls are down 75% due to the unit s decentralised design, which allows for better observation; patient room layout, equipment integration and other design features have helped reduce patient transfers by 90%; overall patient dissatisfaction dropped from 6% in 1998 to 3% in 2001; the decrease in patient transfers and nurses more consistent knowledge of each patient s condition has contributed to an improved medication error index; unit design has helped reduce the caregiver workload index, resulting in improvements in nursing efficiency. The Barbara Ann Karmanos Cancer Institute, Detroit, Michigan Source: The Center for Health Design (2010); Rollins (2004) The Karmanos Cancer institute is affiliated with the Detroit Medical Center and is one of the country s leading cancer research, treatment and education centres. In 1999 and 2000, the institute renovated two inpatient nursing units through the Pebble Project using a number of research projects during the planning process to justify design decisions. Some of the incorporated design features included allocating more space for medication rooms, reorganising medical supplies, installing acoustical panels to decrease noise levels, using softer wall colours, warmer, indirect lighting and pullout sofas for visitors. May 2011 Page 37 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

38 As a result of its design interventions, the Institute achieved the following: nurse attrition rate fell from 23% to 3.8%; patient satisfaction rose 18%; lower daily variable costs per case; reduced pain medication requirements; decrease in medication variances; 30% reduction in medical errors, a result of increased space in medication room, location of medication room, organisation of medical supplies, standardised visual cues and acoustical panels to decrease noise levels; 6% reduction in patient falls, a result of improved lighting and room layout. Designing Out Crime, Birmingham Heartlands Hospital, Birmingham Source: Design Council (2009) In 2002, Birmingham Heartlands Hospital s A&E department reported 700 crimes; a 73% jump from the number of crimes in 2001 and an increase in violent crimes targeted towards staff. Almost 60% of the crimes occurred in patient treatment wards and the emergency department. With the assistance of the Intelligent Space Partnership which conducted design surveys of movements through the department, the hospital determined that the crimes could most likely be attributed to the following factors: the number of people present; the ways in which people were enabled or restricted in their movements through the environment; the restrictions or opportunities afforded by the immediate environment. In this instance, most crimes were occurring due to people entering the building through the wrong entrance, then being guided by natural light and people traffic to the major injuries ward. Other contributing factors included: the patient entrance was less prominent than the paramedic entrance, which had a large canopy over it; the natural wayfinding was poor. People were drawn by light and activity to the wrong areas; signage was not obvious or clear; people entering through the correct entrance came face to face with a wall and a sign pointing them one way to reception when it appeared the medical attention they might need could be found in another direction. There was no immediate eye contact possible with a member of staff. May 2011 Page 38 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland

39 It was determined that the wayfinding and visibility problems were the main contributing factors to the crimes. Therefore, a number of design changes were made which included the following: the removal of signage from the paramedic entrance paramedics knew where to go so they did not require signs; a new foyer incorporating illuminated signage to indicate to patients and visitors that this is the entrance; a new reception area that would address visibility issues and design out crime by promoting levels of natural surveillance. As a result of these changes, the hospital experienced an 80% reduction in trouble incidents, which resulted in a happier and safer staff base. A follow up survey indicated that people were taking the desired route around the department, fewer patients and visitors were wandering into the injuries ward and 88% of people were using the correct entrance to the department. The total use of the paramedic entrance decreased by 55% and aggressive incidents decreased from approximately 13 per month in 2003 to about 5 per month in Provena Mercy Medical Center, Aurora, Illinois Source: Malone et al. (2007) Provena Mercy Medical Center is a 365-bed hospital that sees approximately 12,000 inpatients and 170,000 outpatients each year. The hospital opened a new Outpatient and Surgery Center in 2005 and a new 16-bed ICU in The design of these facilities focused on improving the patient and family experience and includes natural wood, a reception area that resembles a living room, soft floors in the operating rooms and flexibly-moving equipment that enables the surgeon to configure the theatre as needed. Also included are nurses charting areas that are located to maintain visual contact with patients, single-bedded rooms with windows and sinks, wide-entry toilets to minimise falls and windows in the recovery area to enable the flow of natural light. During the change, the facility s vice president stressed process re-engineering and cultural transformation. The improvements enabled the Medical Center to be named the 2007 recipient of the Cardiac Surgery Excellence Award and to be rated in the top 10% nationally for cardiac surgery hospitals. May 2011 Page 39 of 39 Health Facilities Scotland, a Division of NHS National Services Scotland