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Health Record: Invest To Save

Gunnar Ohlen says a whole life costing approach to capital investment in the global healthcare estate will reap long-term rewards.

The world is full of appropriately planned and well-intended healthcare buildings. But, all too often, as a result of financial compromises agreed towards the end of the planning process, the fi nal outcome results in a suboptimal building that fails both patients and the healthcare staff that work there.

As head of a large emergency department, less than 10% of my annual budget and that of the hospital relates directly to the built environment. Yet, every day, it’s possible to observe how the qualities of our healthcare buildings negatively impact on the wellbeing of our patients and staff.

In recent years, one of the greatest infl uences on any decisions I have been involved with in relation to new projects and refurbishments, has been an article by Berry et al1. Berry discusses the impact and need for additional investments to be made in the hospital environment.

In particular, he calls for larger private patients rooms, acuity-adaptable rooms, larger windows and larger patient bathrooms with double-door access, hand-hygiene facilities, decentralised nursing substations, additional HEPA filters, family/social spaces on each patient floor, a health information resource centre, mediation rooms, a staff gym, art for public spaces and patient rooms, and healing gardens.

He explains not only the clinical value of these key features, but also the economic benefits they can bring to the hospital’s bottom line, by reducing patient transfers, falls, nosocomial infections and the costs associated with drug delivery.

Creating a better working environment also has an influence on staff sick leave and turnover. Research at the Karolinska University Hospital by Hagerman et al shows that noise-reduction measures have infl uenced the physiological parameters of cardiac ICU patients as well as staff2.

All too often, however, financial restraints create suboptimal healthcare buildings, resulting in an increased operating cost, which ultimately represents 90% of the overall department and hospital budget. Berry et al suggest another road.

By increasing the initial building investment by 5% above the baseline to improve the quality of care for patients and the working environment for staff, operational building costs can be reduced dramatically, providing a payback time on extra initial investment of only 6-10 months.

In short, there exists a clear choice for those financing our healthcare buildings. Invest at the outset of a project to decrease the annual running cost of the facility by 5% and, depending on the value of the initial investment, after a number of years you will have saved the cost of the entire building. Fail to make that investment and, after the same period, you will have spent the whole building cost again. This is the evidence base upon which capital investment decisions in healthcare buildings should be made, but are we doing enough to make this knowledge available and accessible to the bodies that fi nance our healthcare buildings?

To play devil’s advocate, it might be argued that the capital investment simply isn’t available to build that optimal ten-storey building needed. My answer would be to build nine optimal stories that in turn will generate the capital for another new optimal building. The alternative is being saddled for 40 years with a suboptimal, potentially dangerous ‘white elephant’ building for our patients.

Let’s climb the barricades. Let’s raise our voices. Together we can refuse to build healthcare facilities that are not based on a credible platform of evidence. As Winston Churchill said: “We shape our buildings and, afterwards, our buildings shape us.”
1. Berry LL. Coile RC Jr, Parker D, Reiling J. Facility Design Focused on Patient Safety/Reply. Frontiers in Health Service Management 2004 (Fall); 21(1):3-24.
2. Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA; Theorell T. Infl uence of intensive coronary care acoustics on the quality of care and physiological state of patients. International Journal of Cardiology 2005; 98:267-270.

Author: Gunnar Ohlen MD PhD is head of the emergency department (ED) of the Karolinska University Hospital and president of the European Society for Emergency Medicine (EuSEM).

Nb. This article is a personal view and does not necessarily reflect the position of EuSEM.

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