Hospitals of the future

New hospitals will use creative functional design, replacing bucks with brains.

Hospital cartoon 521 (photo credit: COURTESY OF JERUSALEM REPORT)
Hospital cartoon 521
Everything on this planet not provided by nature (like trees and carrots) is designed by someone. In the case of hospitals, good design can mean the difference, literally, between life and death – or between controlled costs and runaway budgets.
Two key issues trouble hospitals in Israel, the US and elsewhere. First, mistakes that cause patient injury or death. A World Health Organization study showed that one person in 10 is “subjected to a human error in his or her treatment and almost one patient in every 300 dies because of it.” The Journal of the American Medical Association once published a study showing that there were 195,000 hospital deaths every year in the US due to medical error, far more than from car crashes (about 33,000) and nearly all preventable. Some 100,000 deaths alone occur yearly in the US from hospital-acquired infections.
No data exist on error-induced hospital deaths for Israel, but there are persisting hair-raising episodes, like the woman undergoing a Cesarean section at Tel Hashomer’s Sheba Medical Center who was badly burned when antiseptic material on her bed sheets caught fire. The Health Ministry has a quality control section, but crowding and overworked staff continue to cause deaths and injury from errors.
The second issue is soaring costs. New medical technologies are astonishing, and astonishingly costly. Last June, the Supreme Court blasted the Finance Ministry for “emptying of meaning the right to health care [in the National Health Care Law]” by underpaying the country’s four HMOs for patients’ hospital days. At a pricey NIS 2,300 ($600) per day, the reimbursement still does not cover the actual cost.
The fact is Israel’s hospitals are in crisis. The number of hospital beds has fallen from 5.83 per 1,000 in 2007, to just 3.5 per 1,000 in 2010, far below the world average (7.3) and abysmal compared to Switzerland’s 18.3.
Ashdod, a major city, has no hospital. There is a desperate shortage of nurses. The supply of doctors is adequate only because of the fortunate accident of massive aliya from Russia, but many of those immigrant doctors who arrived in the 1990s will soon retire. The 24 state hospitals are overcrowded, with only some 12,000 beds, and many are outmoded. A tiny fraction of the annual NIS 60 billion ($16 billion) expenditure on health care, perhaps three percent, goes toward capital investment.
Jaime Lerner, the Jewish former mayor of Curitiba, Brazil, once said that if you want real creativity, knock two zeros off your budget. I don’t recommend it for Israel’s health care, but his point is a wise one. Lack of money can indeed spur great ideas. Lerner himself practiced what he preached, keeping down the grass in his city’s parks by bringing in goats.
The weighty topic of hospital design was the theme of an international conference on 21st century hospitals held at the Technion-Israel Institute of Technology in Haifa in October. Billed as a “gripping interaction between designers, architects, medical practitioners, academe and decision- makers,” it was held under the auspices of Prof. Noemi Bitterman, who heads the Technion’s industrial design program, along with the Faculty of Architecture and the School of Medicine.
Prof. Shlomo Mor-Yosef, head of the National Insurance Institute, noted that it takes six years to design and build a hospital, which then stands unchanged for 40 years. So hospitals, by definition, are obsolete the moment they open. On the bright side, he described the newly opened building at Hadassah University Medical Center in Jerusalem’s Ein Kerem, where each floor has an indoor “healing garden.”
Dr. Kobi Vortman, CEO of InSightec, brought some striking data. The United States spends about 18% of its GDP on health care, compared with 8% for Israel, yet Israel’s life expectancy at birth is 81.5 years compared to America’s 78.4 years. Not all medical technology raises costs, he noted. His company has developed proven focused MRI-guided ultrasound surgery that removes brain tumors without an incision by dissolving them with a beam of sound, a rare technology that saves money rather than squanders it.
Jos Stuyfzand, a Dutch designer specializing in “Ambient Experience” for Philips, described a remarkable experiment in which Philips designed a special computed tomography scan suite in a Chicago children’s hospital. CT scans are frightening for children; hence, completing one used to take an average of over four hours. By simply making the suite friendlier, less threatening, more reassuring, the time for a scan was slashed to half an hour, and sedation declined by 28%. I think this will work for adults, too. It is not only kids who are scared by CT machines.
Prof. Paul Barach, of the Utrecht University Medical Center in the Netherlands, told a lovely story to show how clever design alone can solve problems: Amsterdam’s busy Schiphol Airport once had a problem with its men’s urinals. Men were missing the target, as they are wont to do, causing germs, odors and costly cleanup. The design solution? Paint a fly in the center of the urinal bowl. Men love to aim and hit targets, and those painted flies are now ubiquitous worldwide. Barach’s point? Technology separates patients and doctors. Use design to bring them together again, reduce errors and cut costs. Substitute creative design for big bucks.
Here are a few design ideas I found, implemented at the new Palomar Medical Center in Escondido, California, just south of San Diego. Palomar itself was hugely costly, coming in at $1 billion, but some of its design innovations weren’t.
For example, there are no nursing stations. (Ever tried to drag a distant nurse to a relative’s hospital bed, or your own?) Instead, there are small workstations outside each room, and next to each is a small closet, so nurses don’t have to rummage through distant supply closets. Each room has Wi-Fi, linked to an electronic medical record system, so medical providers can document care with smartphones or laptops. There are no separate doctors’ and nurses’ lounges. Instead, there is a multipurpose room where doctors and nurses can meet and chat. Outdoor gardens on each floor enable patients to get fresh air without leaving the building. Patients can control their room’s lighting, heating and cooling systems.
Palomar and other hospitals have introduced a simple idea that saves many lives: checklists. Simply list step-by-step the precise procedure to be followed for treating a sick patient, and check off each item. For harried, sleep-deprived caregivers and patients alike, this can be a boon. It works for the air force and for airlines, why not for hospitals? And it costs nothing.
Perhaps it is time to take the design of hospital buildings away from the architects, or at least put control into the hands of patients, doctors and nurses. Blair Sadler, former CEO of a large US children’s hospital, once wrote in an article that “atriums win architecture awards, but they don’t save lives.” For years, my office at the Technion was in a beautiful building with an atrium. That “hole in the middle” kept me from easily interacting with my colleagues, because getting to them took a long hike. Beautiful architecture, bad functional design.
The global economic crisis has caused governments worldwide to slash their budgets. As a result, hospitals have stopped modernizing and upgrading. But much can still be done to prevent error-induced deaths and to control soaring costs. The 21st century hospital will feature creative functional design that replaces bucks with brains. It will become a place where sick people are healed, not killed.
Designers, get to work! We need you.
The writer is senior research fellow, S. Neaman Institute, Technion.