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Service Delivery Innovation Profile

Patient-Centered Hospital Redesign Leads to Low Infection Rates, Higher Patient Satisfaction, More Admissions, and Other Benefits


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Snapshot

Summary

Griffin Hospital renovated a 100,000-square-foot inpatient facility and built a new 49,000-square-foot ambulatory pavilion/cancer center that incorporates patient-centered design factors that are intended to create a homelike atmosphere, including a spacious and barrier-free physical environment; natural lighting, plants, and other elements of nature; carpeting, wood, and soft paint colors; music and art; and common areas such as lounges and kitchens that can be used by patients and visitors. In 2011, Griffin used the same design factors during a major expansion of the emergency department. Although the hospital has not attempted to quantify a direct relationship between outcomes and facility design, hospital administrators believe that the patient-centered design—particularly the decentralized nursing stations—has contributed to declines in infection rates, higher quality and patient satisfaction, fewer calls to nurses, a reduction in malpractice claims, an increase in patient volumes, and better financial performance. It has also been a significant factor in Griffin receiving numerous awards recognizing its high quality care and excellent work environment.

See the Results section for updated information on infection rates, quality performance measures, patient satisfaction rates, malpractice claims, patient volume, awards, and financial performance (updated August 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including infection rates, patient satisfaction, patient calls to nurses, inpatient admissions, outpatient visits, malpractice claims, and financial indicators. The evidence also consists of post-implementation performance on Centers for Medicare & Medicaid Services (CMS) core measures and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, along with various designations and awards received by the hospital.
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Developing Organizations

Griffin Hospital
Derby, CTend do

Date First Implemented

1994

Problem Addressed

The traditional design of hospitals can create a frustrating and somewhat frightening environment in which to receive care, leading to low levels of patient satisfaction and potentially declining market share. A growing body of evidence suggests that patient-centered design can improve patient satisfaction, employee retention, quality, and safety.
  • An antiquated facility, leading to patient dissatisfaction: In the early to mid-1980s, Griffin Hospital had the oldest hospital building in the state and was experiencing declining market share and patient satisfaction as a result. A community perception survey highlighted the negative reputation of the hospital, with almost one-third of community residents listing Griffin as the local “hospital to avoid.”
  • Unrealized opportunity to improve outcomes, patient satisfaction through facility design: The aging condition of Griffin and many other hospitals has led to a building boom for hospitals, with more than $100 billion having been spent on new hospital construction in the United States in recent years and hundreds of billions more likely to be spent in the near future.1 This high level of construction offers an opportunity for hospitals to enhance patient outcomes and satisfaction through better facility design. A literature review identified more than 600 articles in peer-reviewed scientific journals that demonstrate the impact that the hospital environment can have on health status, safety, efficiency, and staff effectiveness and morale.2 For example, one study found that natural lighting can reduce depression, improve sleep, decrease length of stay, lessen agitation, and alleviate pain.3

What They Did

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Description of the Innovative Activity

Griffin Hospital designed its 100,000-square-foot North Wing Patient Care Building to include the following patient-centered design elements: a spacious and barrier-free physical environment; natural lighting, plants, and other elements of nature; carpeting, wood, and soft paint colors; music and art; and common areas such as lounges and kitchens that can be used by patients and visitors. In October 2008, the hospital opened a 49,000-square-foot ambulatory care pavilion and cancer care center with similar design elements and in 2011 did the same during a major expansion of the emergency department (ED). Dedicated staff and volunteers within the facilities are available to greet and assist patients and visitors, with the goal of ensuring as pleasant an experience as possible. Key patient-centered design and staffing features include the following:
  • Easy-to-navigate hospital entry: Entry to the hospital facility is made as nonthreatening as possible through use of the following elements:
    • Easy, pleasant parking: Speakers in the hospital parking lots pipe in soft music; free valet parking is available at the entrance for patients who prefer not to park on their own.
    • Warm, inviting lobby: The hospital’s front entrance and lobby resemble a hotel, with warm decorative elements, including comfortable chairs and a baby grand piano.
    • Welcoming staff: Paid receptionists staff the lobby reception desk, greeting and assisting all who enter. In addition, volunteer ambassadors welcome patients and visitors and offer to escort them to their destinations.
    • Library: A health resource library, open to the community, is adjacent to the main lobby; the library includes mainstream “lay” publications as well as a comprehensive medical library with clinical publications.
  • Comforting transition to patient units: In contrast to the sterile environment in traditional facilities, the hallways are designed to be warm, with woodwork, soft paint colors, carpeting, artwork, soft lighting, and large windows that allow for natural lighting wherever possible.
  • Patient-friendly units: Patient units incorporate the following patient-centered design features:
    • Receptionists: Reception desks are located outside elevator doors on every floor so that all patients and visitors are greeted and assisted if necessary.
    • Warm design: Patient unit hallways have natural lighting, carpeting, artwork, and soft colors, with soft music piped in as well. Top-floor patient units have skylights. Acoustical ceiling tiles reduce sound levels.
    • Decentralized nursing stations: In contrast to the traditional central nursing station, Griffin has decentralized nursing stations into “pods” that allow one nurse to be stationed directly outside of patient rooms, ensuring quick and easy access to patients. Units have one nursing station for every four beds. Nursing stations house medical records and basic medical/surgical supplies.
    • (Mostly) private patient rooms: Approximately two-thirds of patient rooms are private, and even semiprivate rooms are designed for maximum privacy via bathroom and cabinetry placement. All beds have a view of the window, while air filtration systems enhance infection control.
    • Unit-based resource centers: A satellite health resource center is located on every unit, with Internet access and educational books and materials relevant to the conditions treated on the unit.
    • Kitchens, lounges, and entertainment: Each floor has a home-style kitchen, a quiet lounge with comfortable furniture and a fish tank, and an entertainment lounge with a piano where pianists and other musicians come to entertain ambulatory patients and visitors. Some musicians, such as violinists and guitarists, stroll the units.
    • Equipment storage: Each unit has an equipment corridor so that equipment normally stored in hallways is tucked away from patient view.
    • Open medical record: Signs in patient rooms encourage patients to read and make notations on their medical record. On request, the nurse will review the medical record with the patient.
  • Patient- and family-friendly critical care unit: The critical care unit is designed in a unique horseshoe shape, with private rooms forming the horseshoe, an outer ring that serves as the visitor corridor, and a center area for professionals. Patient rooms have doors that access both the visitor and professional areas. Each room also has a private, handicapped-accessible bathroom, which improves infection control. Visitors can stay around the clock; multiple visitor lounges are located around the outside ring, some with sleeping accommodations and shower facilities.
  • Similar principles used in ambulatory care/cancer center and ED designs: The 49,000-square-foot ambulatory care pavilion and cancer care center incorporates similar design elements; it also has an outside waterfall and reflecting pool, which infusion and chemotherapy patients can view while receiving treatment. Similar principles were used in the 2011 redesign and expansion of the ED.

Context of the Innovation

Griffin Hospital is a nonprofit community hospital located in Derby, CT, that is licensed for 160 beds and 20 bassinets; the hospital serves a six-town area with a population of 105,000. The patient redesign program was implemented in response to the aforementioned situation facing the hospital in the early to mid-1980s—that is, an aging facility that was leading to declining market share and patient satisfaction. Hospital board members and administrators considered the possibility of closure or merger with one of seven nearby competitors, but ultimately decided to differentiate Griffin by adopting the Planetree patient-centered model of care and design in 1992. Planetree (http://www.planetree.org), founded in 1978, provides education and information about holistic, humanizing models of patient-centered care.

Did It Work?

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Results

Griffin Hospital has not attempted to quantify a direct relationship between outcomes and facility design because improvements in outcomes may relate to a variety of other factors as well (e.g., clinician and staff performance, systems of care, and targeted improvement initiatives). Hospital administrators believe, however, that the patient-centered design—particularly the decentralized nursing stations—has contributed to declines in infection rates, higher quality and patient satisfaction, fewer calls to nurses, a reduction in malpractice claims, an increase in patient volumes, and better financial performance. It has also been a significant factor in Griffin receiving numerous awards recognizing its high-quality care and excellent work environment. Selected results are as follows (other results are available at www.griffinhealth.org):
  • Lower infection rates: Between 2009 and 2012, Griffin’s hospital-based infection rates fell significantly. For example, the hospital’s methicillin-resistant Staphylococcus aureus (MRSA) rate per 1,000 non-MRSA patient days declined from .065 to 0.04; the vancomycin-resistant Enterococci (VRE) infection rate fell by more than half (from 0.53 to 0.20 per 1,000 non-VRE patient days); and the Clostridium difficile (C-diff) infection rate dropped from 0.87 to 0.55 per 1,000 non C-diff patient days. In 2011, the hospital had no device-associated symptomatic Foley catheter infections and no infections associated with central lines or peripherally inserted central venous catheters. In 2012, the hospital had one Foley catheter infection, one central line infection, and no cases where patients developed pressure ulcers or ventilator-associated pneumonia. (Updated August 2013.)
  • Better performance on core quality measures: Information provided in August 2013 indicates that Griffin Hospital’s performance on CMS core measures (25 measures related to care for heart attack, heart failure, pneumonia, and surgery) ranked second overall in the State of Connecticut, with an overall average of 98 percent. This figure also places Griffin in the top 10 percent of the Nation’s hospitals. In August 2010, Griffin achieved 100 percent scores on all CMS core measures for the first time.
  • Higher patient satisfaction: Information provided in August 2013 indicates that, between 2004 and 2012, 97 to 98 percent of inpatients at Griffin Hospital indicated they were “very” or “somewhat” satisfied with hospital services, up from approximately 80 percent in the mid-1990s. Anecdotally, program leaders believe the decentralized nursing stations have been a major factor in this increase. On the HCAHPS survey for 2011 to 2012, 74 percent of patients gave Griffin Hospital a rating of 9 or 10, well above the 67-percent average for all U.S. hospitals and the 66-percent average for Connecticut hospitals. For this measure, Griffin Hospital ranked sixth out of 29 Connecticut hospitals. Outpatient satisfaction rates averaged 97 percent between 2006 and 2012, and overall satisfaction with the ED reached 96.5 percent in fiscal 2011, the highest rating the hospital ever achieved. (Updated August 2013.)
  • Fewer calls to the nurse: The incidence of patients pressing the nurse call button has fallen by 40 percent since the nursing stations were decentralized.
  • Fewer malpractice claims: Griffin Hospital’s commitment to a patient-centered care philosophy and its focus on patient safety as a cornerstone of high-quality care have resulted in a dramatic reduction in malpractice insurance claims and losses. The number of claims against the hospital dropped from 32 in 1996 to 18 in 2005, a decline of more than 43 percent during a period when annual discharges increased by 40 percent. Since 2006, the average number of claims per year has fallen much further (to two), although other factors, including implementation of a Quality Council structure, have also contributed to this decline. (Updated August 2013.)
  • More patients: Griffin Hospital’s inpatient admissions increased by approximately 28 percent between 1997 and 2009 (from 5,866 to 7,533), well above the 10-percent increase experienced by the typical U.S. hospital. Over the same time period, admissions generally remained flat across Connecticut hospitals, with some experiencing declines. Between 1998 and 2012, annual outpatient visits grew from 93,347 to 196,386, a jump of 110 percent. ED visits reached an all-time high in fiscal 2012. (Updated in August 2013.)
  • Better financial performance: According to information supplied in August 2013, annual net patient revenue increased from $81.5 million in 2003 to $120 million in 2012, averaging about 4.4 percent annual growth over that period. Hospital revenues have exceeded expenses every year from 1999 to 2011, with the exception of 2003, when the inpatient psychiatry unit was closed for renovation. (Updated August 2013.)
  • Recognition for quality, value, and exceptional patient experience: Griffin has received awards from various national organizations that measure and monitor hospital performance, including the Premier Healthcare Alliance Award for Quality (earned each year from 2007 to 2010) and multiple awards from HealthGrades, including the Distinguished Hospital for Clinical Excellence Award (received each year between 2009 and 2012) and the Emergency Medicine Excellence Award (2011 and 2012). Griffin was also recently ranked first in Connecticut by CareChex for overall medical care and major neurosurgery. In addition, Griffin is 1 of 35 hospitals in the world to be designated as a Planetree Patient-Centered Hospital Site, meaning that it meets Planetree’s rigorous criteria for identifying hospitals that have comprehensively implemented and sustained a culture of patient-centered care. (Updated in August 2013.)
  • Recognition for its excellent work environment: Griffin is the only hospital to be listed 10 consecutive times on Fortune Magazine’s “100 Best Companies to Work For.” In 2006, it ranked as the fourth best place to work in the entire country, the highest ranking ever achieved by a hospital. (Updated August 2013.) 

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including infection rates, patient satisfaction, patient calls to nurses, inpatient admissions, outpatient visits, malpractice claims, and financial indicators. The evidence also consists of post-implementation performance on Centers for Medicare & Medicaid Services (CMS) core measures and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, along with various designations and awards received by the hospital.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Conducting background research: Administrators planned 12 monthly workforce retreats to discuss their goals and ideals related to creating a patient-centered environment. Administrators also held focus groups and conducted surveys with patients and community residents and visited hospitals across the country to identify key elements of patient-centered care.
  • Developing a vision: A consulting firm was hired to assist board members, administrators, and staff in developing a shared vision for patient-centered care.
  • Designing the renovation: Architects designed a renovation plan based on hospital site visits (which let them experience the physical plant from the viewpoint of the patient) and suggestions from employees and community residents.
  • Getting regulatory approval: Hospital administrators sought and received approval from the state of Connecticut. Approval was granted on the condition that the hospital could renovate the facility at the same cost per square foot as for other facilities being approved at the time.
  • Addressing physician resistance: Nurses were generally supportive of the renovation, but physicians resisted certain aspects, such as carpeting the hallways and playing piped-in music overhead. To alleviate these concerns, administrators held informational breakfasts and lunches to tell physicians about their vision for a patient-centered approach to care. Nurses also developed an “Adopt a Doc” program, with each nurse selecting a physician to convince of the value of the renovation.
  • Ongoing training: All employees attend a 2-day retreat in which hospital care is simulated from the patient's point of view. During these sessions, staff members are asked for their ideas about service enhancements and design improvements. Refresher training sessions and retreats occur on an ongoing basis.

Resources Used and Skills Needed

  • Staffing: The redesign required no new staff; paid receptionists were reassigned from other positions, whereas volunteers serve as patient ambassadors, assisting patients and visitors in navigating the facility.
  • Costs: The total cost of the redesign was $31 million.
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Funding Sources

Griffin Hospital
Griffin Hospital funded the renovation by borrowing from a quasi-governmental funding agency called the Connecticut Health and Education Facilities, an authority through which tax-exempt bonds are issued. Financing the renovation in this manner allowed the hospital to borrow funds less expensively than through commercial lenders.end fs

Tools and Other Resources

Information about Hospital Consumer Assessment of Healthcare Providers and Systems is available at: http://www.hcahpsonline.org.

Resources regarding patient-centered design are available at:

Adoption Considerations

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Getting Started with This Innovation

  • Develop a shared vision: Hospital leadership, staff, and physicians must develop a consensus around putting the patient first and creating an exceptional patient experience. In particular, hospital leadership must have passion for and be committed to patient-centered care and demonstrate that passion to the entire work force.
  • Invest in culture change through training: Changing staff culture is harder than building a facility. Ongoing training is critical to maintaining a focus on the patient experience.

Sustaining This Innovation

  • Elicit ongoing feedback: Conduct patient and staff surveys on an ongoing basis and use this feedback to create further improvements in the facility design and patient experience.

Additional Considerations

Approximately 125 hospitals have been designed according to the Planetree patient-centered model of care.

More Information

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Contact the Innovator

Kenneth Roberts
Director Communications and Public Affairs
Griffin Hospital
130 Division Street
Derby, CT 06418
(203) 732-7432
E-mail: kroberts@griffinhealth.org
www.griffinhealth.org

Innovator Disclosures

Mr. Roberts reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Agency for Healthcare Research and Quality. Transforming hospitals: designing for safety and quality. AHRQ Pub. No. 07-0076-1. September 2007. Available at: http://www.ahrq.gov/transformhospital.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Flower J. Five-star hospitals. Strategy+Business. Issue 42. Available at: http://www.strategy-business.com/article/06108.

Mycek S. Under the spreading planetree. Trustee. 2007 Mar:22-25.

Arneill B, Frasca-Beaulieu K. Healing environments: architecture and design conducive to health. In: Frampton SB et al., editors. Putting patients first: designing and practicing patient-centered care. San Francisco: Jossey-Bass; 2003.

Footnotes

1 Clancy C. Designing for safety: evidence-based design and hospitals. Am Med Qual. 2008;23(1):66-9. [PubMed]
2 Ulrich R, Quan X, Zimring C, et al. The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity. The Center for Health Design. June 2004. Available at: http://www.healthdesign.org/chd/research/role-physical-environment-hospital-21st-century?page=1
3 Joseph A. The impact of light on outcomes in healthcare settings. The Center for Health Design. August 2006. Available at: http://www.healthdesign.org/chd/research/impact-light-outcomes-healthcare-settings?page=1
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 20, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 30, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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