Care Redesign 2016

How Our Community Designed a Better Hospital

Article · December 17, 2015

For most people in health care, being involved in designing a new hospital is a once-in-a-lifetime opportunity to transform both their work environment and the care they deliver. We at University of Texas Southwestern Medical Center certainly feel that way about our William P. Clements Jr. University Hospital, which opened in December 2014. For its significant improvements in quality and accountability, our hospital received the Rising Star Award from the University HealthSystem Consortium. We attribute much of our success to making patients and front-line health care professionals the true architects of the project. I’d like to share the features of our innovative planning process, with an eye toward helping other institutions adopt the elements that will work for them.

Restructuring the Hospital Design Process

UT Southwestern’s president, Daniel K. Podolsky, MD, sought to place the interests of patients above all else in integrating the new hospital’s clinical-care, research, and educational missions. As chair of the executive committee that oversaw the entire project, he commissioned 12 planning groups (comprising 150 physicians, nurses, other staff, trainees, patients, and community members) who met weekly for three months.

Planning groups are nothing new, of course, but we approached them differently. Instead of merely reacting to ideas from architects and consultants, our groups were led by faculty and staff (chosen for their dedication to patient care) who focused on the broader mission, not just the beds and beams. In our initial meetings, the architects were encouraged to listen, rather than talk, before they began to sketch. We also hired a second architecture firm to take minutes during these meetings and then to do the research requested by the planning group members and the architects from the primary firm.

Although the architects were initially concerned that this nontraditional planning-group format might slow things down, they soon acknowledged that it improved the quality of the decision making and, ultimately, accelerated progress.  All of the stakeholders came to see that their task was not to respond to a settled plan, but to generate information for identifying the best-possible collaborative design. Meeting attendance exceeded 90% — no small achievement for a group of busy providers. And the entire design phase, from inception to approval of construction documents, lasted only nine months.

Directly Involving Patients

No one understands a hospital’s strengths and weaknesses better than patients and their families. Rather than merely soliciting their general input on the hospital’s design, we asked about their specific needs — what worked well and what could be better. Here are some examples:

  • We learned that leaving the hospital through a main entrance, at a time when most people don’t feel or look their best, was often embarrassing for patients. We therefore designed a separate discharge exit with designated parking and a pathway that avoids public spaces.
  • Family members asked for comfortable furniture in patients’ rooms. So we placed all the furniture options in our existing hospitals for several months and had families vote on their preferences.
  • People wondered why digital connectivity, present in nearly every facet of life, is often lacking in medical settings. So we developed an application that allows for secure videoconferencing with family, friends, or a hometown physician via a large, interactive flat screen installed in each patient’s room.

Some of our best ideas for improving the care experience of patients came from the patients themselves — and those ideas directly informed the work of our planning groups.

Seeking Outside Expertise

In addition to getting input from more than 20 hospitals that are known for both high-quality care and excellent patient services, our planning groups looked beyond traditional health care environments. We invited presentations from designers of major hotels and airline lounges, who taught us about functional waiting areas and sustainable furniture and materials. We looked to companies like Texas Instruments to learn about moving and storing supplies — and to airports, museums, and shopping malls for advice about simple, easy-to-use wayfinding aids.

Visiting a hospital is stressful enough — visitors don’t also need to get lost. We therefore designed every guest elevator to open to the same view — of the street where guests enter and the visitor parking garage. And in case someone visits when a patient cannot see guests, we have enabled visitors to leave an electronic “Sorry I missed you” get-well card on the patient’s in-room video monitor.

Instead of waiting until the “last responsible moment” to choose the right technology (so that it wouldn’t be obsolete), we focused on selecting the best technology partners early — ones that promised us their most cutting-edge products when we opened. We lined up most of our vendors more than two years in advance. Having the certainty of our business changed their priority from selling to innovating so that, in effect, vendors became our design partners, invested in making our hospital a showcase for their products. Because the technology specs and operational logistics were finalized collaboratively early on, change orders were about half the typical number for a project of this size. And that saved everyone time and money.

Testing the Design and Assessing Results

Before starting construction, we collected written feedback on our plans and mock-ups from more than 600 nurses, physicians, staff, patients, and community members. They evaluated everything — the spatial layout, materials, furnishings, and finishes. Durability is critical in hospitals, so we asked our environmental-services staff to actually clean the mock-ups. Then we used their input to select materials and build patient rooms that are easier to clean.  As the layouts evolved, we also used computer simulations of staff’s physical movements to identify optimal adjacencies, particularly of supply rooms and waiting areas, because less time spent walking means more time with patients.

Did everything go perfectly? Of course not. Looking back, we see that we could have involved our front-line staff more in deciding how we deliver and stock materials. For example, we and the staff recognized that the contents of bins in our new supply rooms were not easy to identify and that some bins and shelves were too small. Rather than wasting time on a makeshift solution that was unlikely to satisfy staff for the long term, we quickly rebooted and deployed a different system that, this time, the staff helped us craft.

Designing the hospital has been the transformative experience we had hoped for when we began our planning. The hospital opened five months ahead of schedule and has won national recognition for quality and safety in its first year of operation. The project came in substantially under budget, and we used the savings to make the hospital even better. We added another patient-care floor, a second parking garage, and an above-ground roadway to give staff easy access to our academic and ambulatory campuses.

We believe that we achieved these successes because we invested time, energy, and vision in the planning process and fully engaged the people who ultimately benefit most from the hospital — our patients and the community of providers who care for them.

Have an Article Idea ­for NEJM Catalyst?

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign 2016

Poor Care Is the Root of Physician Disengagement

When physicians and health care executives disagree over the purpose of medicine, disengagement is the inevitable result.

Population Health: The Ghost Aim

We are finally at a moment in the history of health care when we know what to do to achieve better health, who should do it, and how to get it done.

Health Reform and the Changing Safety Net in the United States

How the coverage provisions of the ACA are affecting safety-net health systems, responses of these systems to payment reform, and future directions in scaling up improvements and innovation in delivery systems.

The MACRA Final Rule: Five Crucial Questions Asked and Answered

MACRA could be bigger than Obamacare for physicians, yet many “barely know anything about it.”

Rethinking the Primary Care Workforce — An Expanded Role for Nurses

In the primary care practice of the future, the physician’s role will increasingly be played by nurse practitioners.

Survey Snapshot: How to Achieve Post-Acute Care Coordination

Commentary from NEJM Catalyst Insights Council members on preferred post-acute networks and the importance of communication.

Implementing Patient-Reported Outcome Measures

PROMs pioneer shares what’s working in a large health system.

A Memo to the Brilliant

Top-down regulation of physicians may have been a factor in Democrats’ defeat. Blind commitment to specific models of payment reform has put much into jeopardy, unnecessarily.

Care Redesign Survey: Strengthening the Post-Acute Care Connection

Ties between health systems and post-acute care facilities are on the rise, but much work remains to truly coordinate care.

The Hard Work of Health Care Transformation

Experience shows that although a changed market may be a helpful precondition to local performance improvement, it hardly guarantees effective operational change.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Survey Snapshot: Genomic Data Is Far…

NEJM Catalyst Insights Council members say that clinical and cost data will continue to be…

Coordinated Care

81 Articles

How Multi-Specialty Hubs Fill a Major…

Kaiser Permanente, Mid-Atlantic States identified a niche for patients seeking immediate care and found a…

Primary Care

100 Articles

How Multi-Specialty Hubs Fill a Major…

Kaiser Permanente, Mid-Atlantic States identified a niche for patients seeking immediate care and found a…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now