Care Redesign

Designing Hospitals That Heal as Well as Treat

Article · June 11, 2018

If we accept the oft-quoted principle that “health is not simply the absence of disease or infirmity,” it follows that the health care system should be in the business of promoting and enhancing vitality as well as treating disease. Yet we set up a false dichotomy: health care is what is delivered in hospitals and clinics, while wellness is what is promoted in spas, yoga classes, and smoothie bars. Health care and wellness operate as separate industries, each with its own ethos. Yet disease and vitality are merely the two ends of a continuum of health. And what helps people stay well also helps them overcome illness and regain their baseline function.

Thankfully, more and more hospitals and health systems are agreeing with this premise and implementing important measures to encourage, and even accelerate, patient recovery.

Enable Rest

Sleep, which boosts immunity, quells the stress response, and speeds recovery, is the most obvious example. Yet in the hospital — an eerie casino of bright lights, beeping, and commotion — sleep is often an afterthought. The answer for most sleep-deprived patients is a sedative like Ativan or trazodone. Unfortunately, sedatives are quick fixes that increase the risk of sundowning and delirium, especially in the elderly.

A hostile sleep environment is punctuated by overnight lab draws, medication administration, and frequent vital sign checks. Certainly, critically ill patients need to be monitored closely and treated appropriately at all hours. However, this is not the case for all hospitalized patients. The standard of care since the 1890s has been to check vital signs every 4 hours, yet there is no data showing that this improves clinical outcomes. In fact, evidence suggests that close to half of patients are unnecessarily awakened overnight for vitals checks, and these disturbances have been linked to negative health outcomes and patient distress.

Thankfully, hospitals are taking note and rethinking practices. To create a more sleep-friendly environment, Massachusetts General Hospital instituted mandatory quiet hours during the evening and early morning when noise is limited and lighting is dimmed. Yale New Haven Hospital reduces unnecessary wake-ups by empowering nurses to align the time they give medicines to patient sleep schedules. And the use of noisy, Zamboni-like machines that clean floors is prohibited at night. The VA New Jersey Health Care system provides patients with relaxing sleep aids such as herbal tea or aromatherapy with lavender oil.

Hospitals should consider other solutions such as adjusting the frequency of overnight checks based on clinical status, substituting medications that require frequent dosing for those dosed less often, and assigning a single nurse to simultaneously draw labs, administer medications, and check vitals.

Elevate Nutrition

In addition to experiencing sleep deprivation, patients who are hospitalized for an extended period suffer nutritionally. Hippocrates understood the folly of ignoring nutrition, declaring famously, “Let food be thy medicine.” Upon admission, patients are often undernourished and their conditions may worsen if they are inadequately screened, if there are too few dieticians for timely consults, or if treatment with medications eclipses the importance of nutritional interventions. We often allow patients to languish for hours, even days, without adequate sustenance as they await procedures and tests. Yet when patients are malnourished, health outcomes decline and morbidity increases in the form of pressure ulcers and impaired wound healing, immune suppression and increased infection rate, muscle wasting, and functional loss. This translates into more complications, longer hospital stays, higher readmission rates and treatment costs, and even increased mortality.

Consider a few potential solutions. First, let’s eliminate any barriers that keep dieticians from fully managing diet orders and orchestrating nutrition care. After all, physicians have next to no training in nutrition sciences. Given the prevalence of undernutrition in the hospital, dietary consults should be the default in admission order sets. And family insight should be leveraged to better understand a patient’s personal and cultural food preferences. When appropriate, family and friends should be encouraged to engage in the healing process by feeding loved ones.

Simultaneously, hospitals must consider feeding patients well not only a core competency, but a point of competitive advantage. Today, most hospitals contract with large food manufacturers and some even have fast food establishments on site. The hidden sugar, refined oils, additives, preservatives, and chemical flavorings found in many hospital meals stoke the inflammation that underlies disease. Instead, more hospitals should be following the lead of places like Henry Ford West Bloomfield Hospital, located near Detroit, which built a greenhouse and accompanying education center to teach nutrition to patients and the community, while providing organic produce.

Encourage Movement

Along with good nutrition, movement is also essential to health, and especially for hospitalized patients. All activities of daily living are predicated on being mobile, yet in the hospital, idleness — with the psychological and often physical attachment to bed — is the default mode. Only a few short days of bed rest can cause a precipitous loss of strength, which accelerates functional decline, leads to frailty, and thereby increases the risk of falling down and falling ill — a vicious cycle.

Studies show that elderly patients hospitalized for medical reasons do not regain their baseline mobility even 2 years later. And not surprisingly, patients who walk more during their hospitalization are discharged earlier and are less likely to be rehospitalized, even after adjusting for prior morbidity and mobility. Researchers also found that increasing the number of steps elderly patients took in the hospital reduced their degree of functional impairment 1 month after discharge. And a study of patients with pneumonia showed that walking early and often shortened the hospital stay, saving an average of $1,000 per patient.

Despite the indisputable benefits of getting patients up and moving, doing so can be challenging given the logistics of patient care. A first step would be to better stratify patients to determine which ones can ambulate on their own and with family members and which need nursing supervision. Along with a nutrition consult, physical therapy should be a default order for all patients. And while a physical therapist is required to do passive mobilization exercises, patients can do active mobilization and muscle strengthening and stretching exercises on their own. Patients could be given a personalized workout plan consisting of a circuit of exercises that can be done in or out of bed, as appropriate.

In the geriatric unit at the University of Alabama at Birmingham Hospital-Highlands, ample handrails, skid-free floors, low-glare lighting, and a walker in every spacious room encourage patients to move. Physicians should be as vigilant about progressing a patient from bed to chair to standing as they are about transitioning off intravenous and on to oral medications.

Facilitate Connections

Finally, an often overlooked but equally important variable in the health and healing equation is social connectedness. A large number of patients, especially the elderly, lack friends and family to provide basic care and companionship. Meanwhile, an increasing number of studies link loneliness in older people to poorer health and earlier death. Depression often underlies and sometimes exacerbates the more acute illness. While the trend toward single rooms certainly helps with infection control, noise levels, and patient privacy, it also increases isolation.

The Ronald Reagan UCLA Medical Center provides volunteer companions in the geriatric unit. Such programs are an excellent opportunity for younger people who are interested in a career in health services to get hands-on experience. Patients benefit from the companionship, while volunteers practice communication skills and become familiar with the hospital workflow. Hospitals should also provide common spaces where patients can gather for communal meals, walks, or discussions. In this way, patients become healers and caregivers for each other. A sense of purpose is a potent remedy.

To date, most hospitals, from the physical layout to the daily workflow, are built for the mechanized, assembly-line approach to treatment. Patients often leave feeling depleted, dehumanized, and functionally debilitated because those basic things that help us stay well — sleep, nutrition, movement, and connection — are not integrated into the design. However, hospitals now face a financial imperative to reduce readmissions and improve satisfaction scores, which provides additional impetus for these essential ingredients for recovery. To begin, hospitals must employ cost-effective but high-yield strategies such as changing workflow and empowering allied health professionals to write activity and diet orders. Longer term, rather than build a new cancer center or purchase a new scanner, hospitals should invest in nutritious food, rehabilitation therapies, and space redesign.

The comprehensive management of illness should include acute medical interventions paired with the advancement of functional recovery. To do this more effectively, hospital leadership should open their eyes and ears to their colleagues in the world of wellness. Together, we can create innovative solutions that incorporate these fundamental tenets of vitality into a more holistic patient care experience.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

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

Learn More »

More From Care Redesign
Summary of Comprehensive Approach to Physician Behavior and Practice Change

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to sustainable change in surgical practice and physician behavior.

Myths and Realities of Opioid Use Disorder Treatment.

Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities

There is a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done.

Coffey02_pullquote family-centered care in medical and surgical procedures

What If Family-Centered Care Were Extended to Medical and Surgical Procedures?

Though the concerns are valid, early experiences suggest that family member engagement may be an effective tool for improving the value of care.

Evidence Needed for Health Systems Change to Address Social Determinants of Health and Obesity and Diet-Related Diseases in Turn

Better Clinical Care for Obesity and Diet-Related Diseases Requires a Focus on Social Determinants of Health

To more effectively treat the problems of obesity and diet-related conditions, health systems need to restructure the traditional medical model of care delivery to address the social determinants of health.

People Living with Dementia Around the World - Value-Based Chronic Illness and Dementia Care

Value-Based Care Must Strengthen Focus on Chronic Illnesses

To effectively control costs and improve value, new models must address our increasingly older patients and chronic care patients, especially those with Alzheimer’s and related dementias.

The Barriers to Excellent Care Vary Widely Across Geographic Regions - both Rural Health Care and Urban Health Care

Survey Snapshot: Rural Health Innovations Born from Challenges

According to NEJM Catalyst Insights Council members, every health system has to develop its own definition of what is meant by “rural” health.

Same-Day Breast Biopsy Workflow at Baylor College of Medicine

How Care Redesign and Process Improvement Can Reduce Patient Fear

Seeing how clinicians take care of their own when they are in frightening situations was the epiphany that led to a same-day breast biopsy program.

Rural Health Care Is Rated Comparable or Worse Across Quadruple Aim Aspects

Care Redesign Survey: Lessons Learned from and for Rural Health

Although care delivery models in rural and urban/suburban areas are distinct, by virtue of geographic density and resource availability, each locale affords lessons for the other.

Comprehensive Intervention Review at Lurie Childrens Hospital - improving patient flow and length of stay

Reducing Length of Stay in the ED

A comprehensive redesign of triage and ED care.

Pumonary Nurse Post-Discharge Follow-Up Note for Patients with COPD

TOPS: Telephonic Outreach in the Pulmonary Service at VA Boston Healthcare System

A nurse-directed intervention targeting veterans who had been hospitalized for COPD resulted in improved access to ambulatory care and a reduced rate of readmissions.

Connect

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

Learn More »

Topics

Social Needs

88 Articles

Better Clinical Care for Obesity and…

To more effectively treat the problems of obesity and diet-related conditions, health systems need to…

A Successful Pilot to Improve Access…

Actionable data and modest financial incentives can help motivate clinicians to adjust their behavior around…

Coordinated Care

129 Articles

The Evolution of Primary Care: Embracing…

Primary care must leverage disruptive innovations to ensure that patients receive first-access, comprehensive, coordinated, continuous…

Insights Council

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

Apply Now