Industry-wide consolidation, regulatory demands and economic pressures have further stressed a healthcare industry already struggling to rein in spiraling costs while improving outcomes. Technological innovation and medical advancements add further complexity.
Healthcare reform continues to reshape the industry. While the status of the Affordable Care Act may change, its intent—to provide care for all Americans while reducing healthcare costs through adequate preventive care—and accompanying mandates have spurred new standards of healthcare delivery that will live on.
A shift from a fee-for-service model to one that bases reimbursement on value is driving fundamental changes in the industry, one in which providers are now rewarded for outcomes and patients take greater responsibility for their care.
Seeking to attract healthy patients as well as the sick, providers strive to deliver a continuum of care to a population that is growing in size and increasing in age. Patients, empowered with choice and well-versed in comparison shopping, seek value and convenience from their healthcare providers.
A more patient-centered, family-focused perspective has emerged, inspiring new models of care delivery. Growing numbers of free-standing ambulatory clinics provide convenient alternatives to traditional hospitals while meeting articulated population health goals.
These trends have far-reaching impact and influence on the design of healthcare environments.
Knoll studied the changing healthcare ecosystem, including speaking with industry observers and experts across the country, to identify the most significant trends driving planning for healthcare environments today. We then conducted one-on-one interviews with more than two dozen physicians and medical professionals, architects, designers and end users to learn about new care delivery models and designs for the changing healthcare landscape.
This brief is the culmination of our study and suggests planning and design strategies to support new models for today’s built environment that also adapt to future standards of care delivery.
Drivers, Culture + Characteristics
While healthcare reform has impacted the industry on numerous levels, modern healthcare environments are also strongly influenced by macro trends including shifting demographics and new technology, as well as the industry’s unique culture and an operations-heavy business model that runs around the clock.
Mergers, acquisitions and consolidations have been rampant in the healthcare industry, hitting a record high in 2015 and showing little sign of abating. Banding together to build a mega-brand healthcare system can create the scale needed to survive in a competitive environment, as well as boost gains in market share, improve operating efficiency, streamline care delivery and increase profitability.
As a behemoth industry that accounts for 17% of U.S. GDP, change in the healthcare industry comes slowly. So, despite a shifting political climate and leadership, policy and program changes take years to develop and roll out.
Oftentimes the biggest challenge to hospital construction is not financial or technical, but cultural, noted Debajyoti Pati, Professor at Texas Tech University. As consensus building organizations, it can be very hard to get leadership and planning team members moving in the same direction. Moreover, lengthy construction schedules tend to add complexity as leadership regimes often transition during a building’s protracted construction phase, which averages 5 to 6 years and up to 10 for federal government facilities.
Even when new models are implemented, change is sometimes slow or met with resistance, according to Dr. Pati, who has observed hospitals maintaining a centralized mode of operations, for example, even after they are re-designed as decentralized inpatient facilities.
As modern medicine extends lifespans, the Baby Boomer population is putting additional demands on the healthcare system as they age. Often called the silver tsunami, this population segment will increase needs for hospice and end-of-life care as well as management of chronic and dementia-related conditions like Alzheimer’s.
Another large and growing population segment is millennials who, as they begin families, will utilize more medical services than they have in the past.
Impact of the Affordable Care Act
Signed into law in 2010 and rolled out in 2014, the Patient Protection and Affordable Care Act (ACA or “Obamacare”) went beyond transforming coverage and care. It opened up a broader dialogue about the basic mission of public health in a nation with universal coverage that continues to this day. With a focus on value and outcomes, rather than volume, it altered the healthcare cost structure and increased the demand for greater accountability.
Expanding insurance coverage and access added 20 million Americans to the 300 million already covered. Though the particulars may be undefined, the new government administration has pledged universal coverage for all Americans, potentially expanding the ranks even further. A larger patient base is likely to trigger a need for more facilities, as well as put greater stress on an already stretched healthcare workforce.
New Approaches in Healthcare Delivery
The centralized, campus-based healthcare economic model that was built around inpatients, surgeries and procedures is rapidly being diluted by lower cost methods of delivery. In large part due to the ACA and its emphasis on population health, but also due to a focus on operational efficiency, changing technology and new models of care delivery, services are moving outside the hospital to new ambulatory outpatient clinics and community health centers.
Triple Aim Concept. One framework based on a patient-centered approach is the Triple Aim concept developed by the Institute for Healthcare Improvement (IHI). Designed to optimize health system performance using a holistic approach with three dimensions, it is considered an extremely ambitious strategy to galvanize system-wide health improvement. Successful implementation of such large-scale changes will likely result in fundamentally new systems that contribute to the overall health of populations and reduce the cost to society.
The premise behind Triple Aim is that new design solutions must address three key dimensions concurrently:
1. Improve the patient experience of care, including quality and satisfaction based on six dimensions (safe, effective, patientcentered, timely, efficient, equitable)
2. Improve the health of populations, requiring the engagement of partners across the community to address the broader determinants of health
3. Reduce the cost of healthcare on a per capita basis via cost control and improve the return on resources invested
The IHI believes that to improve all levels of the system requires harnessing a range of community determinants of health, empowering individuals and families, substantially broadening the role and impact of primary care and other community-based services, and assuring a seamless journey through a lifelong continuum of care.
Since healthcare itself comprises just 10% of multiple determinants of health, political changes are not expected to change a focus on population health, according to Carol Beasely, IHI senior vice president. “The fact is that healthcare is part of a system of health, and includes other elements such as behavioral patterns, genetic predisposition, social circumstances and environmental exposure,” she explained.
Focus On Population Health. Fundamental changes to care delivery—particularly at the primary care level—have emerged to support population health and its multi-pronged focus on proactively preventing disease, prolonging life, and promoting health through organized efforts and informed collective choices. “Even before the ACA, we knew to be successful in the long run required managing three aspects of the system,” IHI’s Beasely explained. “We had to provide great care. We had to be concerned about populations and we had to think about the total cost,” she said.
Hospitals and health systems are now rewarded for offering high-quality care, reducing unnecessary hospitalizations and preventing readmissions. Patient health, including chronic diseases or disabilities, is managed through a combination of behavior change and evidence-based medicine focused both on prevention and treatment of injury and disease.
Collaborative Team Care Model. Team care is a concept with new treatment modalities designed to improve the patient experience. It has been proven to increase the number of patients seen per day, improve satisfaction levels of patients and staff and increase gross patient revenue. With its emphasis on collaboration across disciplines, it is also designed to reduce the “siloed” nature prevalent in much of healthcare to one more in line with the team approach being taught in medical school and already in place in many corporate work environments.
With its multi-disciplinary approach, team care allows for greater interaction between patients and providers as well as between providers themselves through more efficient use of time, space and resources. Instead of the standard clinical model with disconnected individual areas—typically private offices for physicians separated from nursing station and exam rooms—work and social interactions happen in a range of flexible multi-function workspaces. All providers—physicians, nurses, physician’s assistants, therapists and social workers—work side by side in close proximity providing patient care and sharing information.
The expectation is that compliance will be higher if patients depart with care plans from all members of the provider team and that investment of effort will keep the patient from returning with exacerbated conditions, thus improving outcomes and lowering readmissions.
Lean Thinking. Based on the model developed by Toyota, lean thinking identifies and eliminates waste in any activity performed within a facility by focusing on process improvement and change management. The concept of the most efficient use of staff, resources and technology to provide the highest level of service to the consumer is being adopted across the healthcare industry, ranging from daily operations to how to plan the physical environment.
When lean management processes are successfully applied in a clinic setting, patients benefit from more time from clinicians, greater safety, less delay in receiving care and more timely results and treatments. Staff benefit by having fewer steps, less work and greater opportunities to care for patients.
Outpatient Care. Outpatient facilities, such as freestanding emergency and urgent care clinics, ambulatory care centers and medical office buildings, typically under the banner of a mega-brand healthcare institution, bring outpatient services closer to patients in their communities to offer more responsive care while reducing demand for more expensive acute care services.
Clinic designs center on patient flow so providers can serve patients quickly and efficiently. They provide basic services and procedures such as primary, specialty and/ or urgent care; imaging and lab work; and/ or rehabilitation. Patients enjoy convenient access, good parking, extended hours and adjacent community and retail destinations.
Situated in suburban or outlying rural locations, outpatient facilities often serve as a “spoke” to a hospital’s more centralized “hub” or primary location. With a relatively small investment needed, smaller freestanding facilities are an appealing way for hospitals to grow when space is not available at the current facility, or to test expansion into a new community in hopes of growing the patient base. Additionally, less complex design and construction expedites speed to market, allowing institutions to get a jump on the competition and capture market share.
Healthcare institutions are also finding opportunities to reach consumers where they shop and live by repurposing underutilized real estate. Large warehouses, industrial spaces and commercial buildings that formerly housed “big box” retailers are seeing a second life as newly minted outpatient facilities.
Patient Education. Incentives from the ACA may have inspired the establishment of employer wellness programs in some companies, but a proactive focus on healthy living has become the norm for any entity seeking to reduce medical costs. Thus healthcare institutions are prioritizing delivering education to patients and responsible family members through multiple channels, supporting efforts to keep patients out of the hospital.
Healthcare Environment Solutions and Strategies
Producing a superior patient experience depends on three factors coming together: caring staff (people), patient-centered operations (process) and well-designed facilities (place). As the industry transitions to a patient-centered model focused on achieving good outcomes, a positive experience is a key metric, maximizing reimbursement as well as attracting patients.
The built environment plays an integral role in supporting these new models of care delivery. Environments must respond to healthcare’s new paradigm with flexible, multi-purpose, technology-enabled spaces that meet today’s standards of patient care, family involvement and multi-disciplinary care teams with increased patient satisfaction, caregiver productivity and throughput. Our research suggests five strategies to successfully create such spaces.
1. Enhance the Patient Experience to Promote Healing and Comfort.
A holistic approach that engages multiple senses and addresses emotional and spiritual needs can reinforce healing efforts on a deeper scale.
2. Provide Spaces and Comforts for Family and Staff.
A large component of patient-centered care relies on family support, including in-person stays with patients. “The concept of having square footage dedicated to family is hardwired now,” said Todd Cohen, Director of AtSite. “It’s the norm. And when the average length of an ICU inpatient stay is 5 days or more, family members need alternatives and respites from patient rooms.”
Creating a sense of change of venue for visitors and patients might be achieved with variations in furniture styles, types and colors between patient rooms and waiting spaces, according to Jennifer Eno, Senior Interior Designer at NYU Langone.
With stays in rehabilitation centers averaging even longer—around 20 days—facilities are dedicating significant amounts of public space to assure the comfort of family and friends who accompany patients.
3. Look to Other Industries for Inspiration.
With heightened emphasis on patient satisfaction, and a savvier healthcare customer, designers look to industry models outside healthcare for inspiration and strategies adaptable to healing environments. The airline, retail and hospitality industries provide relevant lessons in creating inviting environments that deliver a superior customer experience.
4. Lean Approaches to Alternative Care Models and Modern Workplaces.
In the healthcare environment, where managers are asked to do more with less (staff, technology, time and workspace), the tenets of lean thinking—reducing waste, improving productivity and efficiency and achieving the best clinical outcomes—are increasingly prevalent in spaces that support new modes of care delivery. Among frequently employed lean strategies are reducing the number of people necessary for a process, automating as much as possible and eliminating waiting times.
However, leaner does not necessarily mean smaller. “You get better throughput if you have a little more space,” expressed Dr. Tingwald, “as well as significant operational savings.”
At St. Louis Children’s Hospital Specialty Care Center, designers organized the overall floorplate to streamline travel distances and separate traffic flows while providing flexibility between different suites as volumes change over time. Space is organized so circulation paths yield continuous views of the landscape from public corridors and waiting rooms while also providing daylight and wayfinding cues.
5. Design for Flexibility.
It has been said that the only true hospital of the future is the one that maximizes the ability to accommodate change. Building in flexibility in spaces and furnishings wherever possible is the best insurance of creating an environment that can adapt smoothly as medicine and technology further advance.
Change may be slow in healthcare, but the reality of economics and industry reform measures, combined with a growing, consumer-savvy patient base, are forcing healthcare providers and the architecture and design community to adapt quickly and develop new, innovative solutions.
As the healthcare industry continues to change and reinvent itself, institutions are challenged to respond with models that meet three primary goals: improving the patient experience, improving the health of the population and reducing the per capita cost of healthcare and deriving greater ROI on investment.
New models respond to the changing agenda, as well as the shifting healthcare workplace, which is much more collaborative than it was in the past.
Industry changes are urging re-thinking of physical spaces to support team-based care delivery, the ever-advancing medical technologies they utilize on a daily basis and the communication technologies that connect them to consultants in other locations.
A more market-driven model is emerging, empowering consumers with choice and inspiring institutions to deliver a positive healthcare experience. Fresh thinking has resulted in environments that make both the patient and family experience much more pleasant. Taking cues from industries such as retail, hospitality and the airlines, designers and planners are creating spaces that are a far cry from clinical institutions of the past, and more closely resemble lounges, fine restaurants and branded hotel experiences.
With the advent of patient choice, convenience, comfort and education, institutions can achieve a higher satisfaction rating, better patient experience and positive outcome.
Among the most successful environments are those that start with lean thinking, re-examining each and every step in the process to eliminate waste and allow for future flexibility.
Leveraging the power of design can add value beyond providing excellent care in the healthcare built environment. It can create a welcoming environment that attracts patients and delivers a superior experience to patients, family, visitors and staff. It can also respond to the needs of the community; support recruitment and retention efforts, improve operations and efficiency and ultimately drive financial success.
More changes are in store on the healthcare front. Despite uncertainty about the next phase of healthcare reform, demographics favor continued growth in the healthcare sector. Industry prognosticators and institutions maintain a bullish outlook as well. The American Institute of Architects forecasts that construction spending will double in 2017, and Healthcare Facilities Management reports that 19% of health systems had an ambulatory project underway in 2016 and 18% are planning a new one in 2017. By providing the ultimate in convenience, technology applications are poised to revolutionize the industry, connecting providers with patients in any location and improving access to healthcare while achieving greater accuracy and efficiency. Dr. George Tingwald predicts virtual care will drastically shrink the number of clinic visits and ultimately space requirements, much like technology has replaced many bank tellers and travel agents.
Ninety-two percent of executives expect that the hospital of the future will not be a hospital at all and that high value post-acute care networks will be a key area of focus over the next three years. However, 94% feel creating such networks will be their greatest challenge in that same time period, according to Premier’s Economic Outlook Survey.
Some states such as California already have highly market-driven programs in place that recognize the strength of the patient consumer and will likely serve as models for other states to adapt.
The future of healthcare relies on successfully integrating the new outcome-based model and its accompanying mindset based on patient self-management and accountability. Success also hinges on patient management of lifestyle and chronic conditions, the most common and costly of all health problems, but also the most preventable.
Early reports show the new outcome-based model is succeeding at an economic level. Research recently found that U.S. hospitals that deliver “superior” customer experience achieve net margins that are 50% higher, on average, than those of hospitals providing “average” customer experience. The study by Accenture compared six years of hospital margin data with HCAHPS scores and found that hospital margins and revenues among the top HCAHPS performers are growing at an above-average rate and revenue growth is outpacing expenses in these hospitals.
As attitudes and policies change, and delivery models continue to shift, the built environment will play a significant role in American healthcare and the corresponding patient experience, one likely to affect virtually every individual at one point in their life.
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A special thanks to the following individuals:
Lilliana Alvarado, CHID, EDAC, IIDA, NCIDQ,
New York, NY / Bedford, NH
Managing Director, Principal, Health &
Wellness Practice Leader
Director, Supply Chain Sustainability
Holy Cross Health
Montgomery County, MD
National Director, Strategic Real Estate
Planning & Transition
Catholic Health Initiatives
Senior Vice President
Institute for Healthcare Improvement
Lisa Bonnet, NCIDQ, LEED AP
Morris Switzer Environments for Health, LLC
Rebecca Brown, IIDA
Director of Business Development
Creative Business Interiors
Todd M. Cohen, FACHE, EDAC
Tama Duffy Day
Firm-wide Leader of Health &
Geraldine Drake, NCIDQ, LEED Green
Interior Design Director
Quinn Evans Architects
Ann Arbor, MI
Senior Interior Designer
NYU Langone Medical Center
New York, NY
Ardis Hutchins, AIA, IIDA, CHID, EDAC
Andrea V. Hyde, CHID, MDCID
Director - Design and Architecture
LifeBridge Health Real Estate, Planning &
ZGF Architects LLP
Associate, Healthcare Planner & Project
McMillan Pazdan Smith
University of Texas MD Anderson
Debajyoti Pati, PhD, FIIA, IDEC, LEED AP
Professor and Rockwell Endowment Chair,
Department of Design
Texas Tech University
ZGF Architects LLP
Jocelyn Stroupe, CHID, EDAC, IIDA, ASID
Dr. George Tingwald
Director of Medical Planning,
Design & Construction
Stanford Health Care
Menlo Park, CA
References & Additional Reading
Accenture. 2016. “U.S. Hospitals that Provide Superior Patient Experience Generate 50 Percent Higher Financial Performance than Average Providers, Accenture Finds,” May 11, https://newsroom.accenture.com/news/us-hospitals-that-provide-superiorpatient-experience-generate-50-percenthigher-financial-performance-than-averageproviders-accenture-finds.htm
Barista, David. 2013. “Five radical trends in outpatient facility design,” Building Design & Construction, February 14, http://www.bdcnetwork.com/5-radical-trends-outpatientfacility-design
BaRoss, Carolyn. 2015. “Designing for Health: Responding to Shifting Patient Demographics Through Empathetic Design,” Contract Magazine, September 15, http://www.contractdesign.com/practice/healthcare/Designing-for-Health-Responding-to-Shifting-Patient-Demographics-Through-Empathic-Design-36790.shtml/
Barker, John and Ed Pocock, AIA and Charles Huber. 2015. “The Future of Ambulatory Care,” Practicing Architecture Knowledge Communities, American Institute of Architects, http://www.aia.org/practicing/groups/kc/AIAB086508
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