SummaryThe Samuel Oschin Cancer Center, part of Cedars-Sinai Medical Center in Los Angeles, redesigned physical aspects of the outpatient facility to incorporate features that create a soothing, healing environment for patients. Patient-centered design elements include a patient-centered infusion area; natural lighting, plants, and other elements of nature; soft paint colors; comfortable furniture; and a configuration that facilitates nurse access to patients. Data collected from 2004 through 2009 indicates that the redesign led to increases in patient and staff satisfaction.Moderate: The evidence regarding patient and staff satisfaction was evaluated with pre-and post-implementation measurement, as well as with anecdotal reports of staff satisfaction.
Developing OrganizationsCedars-Sinai Medical Center
Los Angeles, CA
Date First Implemented2004
Planning began in 2004 for a 5-year project, and construction commenced in 2005.
Problem AddressedPoor hospital design can create a frustrating and somewhat frightening environment in which to receive care. A growing body of evidence suggests that patient-centered design can improve patient and staff satisfaction, employee retention, and health care quality and safety.
- Aging hospitals driving a "building boom": Approximately $100 billion has been spent on new hospital construction in the last 5 years, and an estimated $250 billion more will be spent through 2020, as hospitals redesign old wings and build new ones.1
- Link between hospital environment and health: The need for new construction offers an opportunity to enhance patient outcomes. A literature review conducted by the Center for Health Design identified more than 600 articles in peer-reviewed scientific journals demonstrating the hospital environment's impact on patient health, safety, efficiency of care, staff effectiveness, and staff morale.2 For example, a study of lighting in hospitals found that use of natural lighting can reduce depression, improve sleep, decrease length of stay, lessen agitation, and alleviate pain.3 Other studies have found links between improved design and reductions in medication errors, patient falls, and hospital-acquired infections.4
Description of the Innovative ActivityPatient-centered design elements at the 78,000-square-foot Samuel Oschin Cancer Center include individual infusion bays; natural lighting, plants, and nature-inspired artwork; comfortable furniture; and a configuration that facilitates nursing care. Key features include the following:
- Individual infusion bays: The redesign created 13 private infusion bays with individually controlled thermostats and lighting to accommodate the comfort of patients. Bays are equipped with visitor chairs, flat-screen televisions, DVDs and DVD players, and wireless Internet access so that patients can use their laptops. Movable screens allow patients to choose their preferred level of privacy. The hospital purchased comfortable, reclining infusion chairs that allow patients to lie flat, after patients tested several prototypes during their 1- to 6-hour treatment regimens.
- Natural lighting: Soft-light table lamps replaced fluorescent lighting in waiting areas, along with backlit panels in the individual infusion bay area that shift over time to reflect changes in daylight (rose in the morning, white at noon, and lavender in late afternoon). Because the center is underground, the only natural light comes from the ceiling; the design ensures a flow of natural light. By combining the natural light with high ceilings and an open design, the center does not have an underground "feel."
- Comfortable furniture: New, comfortable furniture with appealing fabrics has been installed, with chairs clustered into small groups. Benches placed at strategic locations provide resting spots for patients.
- Warm paint colors and design materials: Bathrooms have been repainted in warm earth tones, whereas hallways are painted in cheerful colors. Stone, granite, wood, and glass design elements add to the warm feel of the facility.
- Elements of nature: Vibrant, colorful artwork inspired by nature hangs in infusion rooms, bathrooms, and other patient and staff areas. Plants, fresh flowers, and trees placed throughout the center give the facility a natural, life-affirming feel. The backlit panels all depict photographs of nature and are in pastel shades; for example, there is a panel with rain drops enlarged and another with the veins in a leaf. "Water effects," such as fish tanks, are also used in the center.
- Configuration to facilitate staff convenience and appeal: Under the former rectangular design of the infusion area, staff members needed to walk a long distance to obtain supplies and round on patients. With the square configuration in the redesigned area, the infusion bays encircle the nursing station, leaving nurses only about 8 to 10 feet from each patient. Each infusion bay is fully stocked with supplies, with extra supplies located in a centrally located storage area by the nursing station. Nursing lounges have also been upgraded through the use of paint colors, furniture, and artwork designed to promote healing.
- Improved way-finding: The redesign included efforts to help patients find their way around the center more easily, including placing information desks immediately outside the elevator banks, using escorts to help patients get to appointment locations, and improving written and pictorial signage. These improvements have been especially important given the ongoing construction and expansion at the center.
- Ongoing input from Patient Advisory Council: A 50-member Patient Advisory Council meets monthly to receive updates and provide input on various design projects, such as selecting paint colors or testing reclining chemotherapy infusion chairs. In some cases, council members provide input via e-mail on relatively straightforward issues. (Note: Providing input on the expansion was just one of many Patient Advisory Council accomplishments.)
Context of the InnovationCedars-Sinai Medical Center is a 952-bed medical center located in Los Angeles. Each year, the medical center's Samuel Oschin Cancer Center treats more than 9,000 patients and has approximately 110,000 visits. The cancer center is located on the basement level of the medical center. The original infusion center has a full-length and width skylight. The new short infusion area receives its only natural light from a narrow row of skylights along one side of the space. Having been in its current space since 1988, the cancer center originally won awards for its modernistic architectural design, characterized by a black/white/gray color scheme, fluorescent lighting, modern art, hard edges, and industrial surfaces. This design reflected then-held beliefs that these elements would inspire confidence in the institution's ability to fight cancer using state-of-the-art technology. However, outpatient satisfaction surveys revealed that many patients felt that the physical environment was "scary," "cold," "noisy," "depressing," and "drab." With increases in patient volume, the center had outgrown its facility and required reconstruction; the center's leadership used this expansion as the opportunity to redesign the facility with a view toward a patient-focused healing design.
ResultsThe Samuel Oschin Cancer Center redesign has led to increases in both patient and staff satisfaction, as measured by pre- and post-implementation survey instruments.
Moderate: The evidence regarding patient and staff satisfaction was evaluated with pre-and post-implementation measurement, as well as with anecdotal reports of staff satisfaction.
- Higher patient satisfaction: There are a number of quantitative scores to reflect the impact on patient satisfaction:
- Overall patient satisfaction: Overall patient satisfaction scores from the Press Ganey Outpatient Cancer Center tool rose from 86.5 in 2004 to 88.6 in 2009. This is remarkable considering that the center was undergoing major construction in the patient treatment areas during this entire timeframe. Data from the hospital's 2009 internal expansion survey indicate that patients and family/friends are highly satisfied regarding their needs being met by the expansion.
- Waiting area comfort: Scores for "waiting area comfort" declined in 2007 to 82.9 when construction forced the removal of all tables and soft chairs and replacement with narrow-designed, straight-backed chairs so that more patients could be accommodated in a smaller space; however, the scores in 2009 increased to 84.8.
- Infusion area comfort: Scores for the comfort of the infusion area decreased from 88.1 in 2004 to a low of 85.9 in 2006; however, in 2009, scores for this measure reached an all-time high of 90.9.
- Likelihood of recommending services: Scores for "likelihood of recommending services" rose from 93.2 in 2004 to 95 in 2009.
- Higher staff satisfaction: Staff survey data indicate that staff satisfaction has increased from a score of 4.06 (out of 5) in 2005 to 4.37 in 2009. Overall job satisfaction steadily increased during this time period, despite ongoing construction that caused crowded workspaces and other inconveniences. Although staff have suggested a need for more space, qualitative results suggest that nurses are generally satisfied with the redesign, noting their appreciation for aesthetic improvements (e.g., "calming" and "beautiful"). Center administrators believe that the redesign will ultimately lead to an increase in nurse retention.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Reviewing satisfaction surveys to plan initial improvements: The director of business development reviewed patient satisfaction survey reports and began working with the facilities manager to determine how to make the physical environment more appealing to patients. Certain issues were addressed on a piecemeal basis, such as temperature control.
- Conducting literature review and site visit: The director of business development began reading the literature about patient-centered redesign, including information from the Center for Health Design. She also visited Karmanos Cancer Center's inpatient cancer unit in Detroit; this was the second facility to join the Center for Health Design's evidenced-based design research project, known as the Pebbles Project.
- Hiring architects, designers, and consultants: The hospital only solicited bids from architects and interior design firms with experience in healing design. The hospital also contracted with an art consulting firm (American Art Resources) that specializes in using art to create healing environments. Finally, the hospital hired a "way-finding" consultant to suggest improvements to help patients find their way around the facility more easily.
- Conducting patient survey: In May 2005 (before construction began), the center administered a patient-focused Healing Design Survey to 9,000 patients to obtain feedback about their design preferences. The survey included mostly open-ended questions, such as the following:
- "What features would make you and your family members feel more comfortable when visiting the Cancer Center?"
- "What is your idea of a supportive healing environment?"
- "What are the things you like least/most about the interior design of our current space?"
- Analyzing survey responses: Program leaders analyzed survey responses and prioritized areas of concern. Top priorities included more comfortable furniture; softer lighting; natural warm color rather than white walls; spacious and warm waiting areas; and happy, nature-inspired, life-affirming artwork.
- Holding multistakeholder meetings: Hospital executives, nursing staff, and a group of patients met with the architects and designers during multiple, intensive sessions to develop and provide feedback on designs. Cancer center administrators, nursing staff, nursing management, and the Patient Advisory Council regularly met with the architects and interior designer throughout the project.
Resources Used and Skills Needed
- Staffing: The redesign itself required no new staff, although the concurrent expansion of the infusion center added patient capacity, thereby generating a need for additional staffing.
- Costs: Data on actual costs are unavailable; however, the Cancer Center estimates that implementing the healing design environment added approximately 18 percent to the architectural fees and 12 percent to the construction costs.
Funding SourcesCedars-Sinai Medical Center
Tools and Other ResourcesInformation and resources on patient-centered design are available from the Center for Health Design at http://www.healthdesign.org.
Getting Started with This Innovation
- Refer to published literature to gain support for redesign: A wide body of published literature exists on how an investment in healing design can pay off in terms of both clinical and financial outcomes. Advocates can highlight these research findings to garner support for redesign from institutional leaders.
- Develop a common vision: Hospital leaders, staff, and physicians must agree to put the patient first and create a healing, comforting atmosphere. In particular, hospital leadership must have passion for and be committed to patient-centered care and demonstrate that passion to the entire workforce.
- Visit other centers known to have successfully implemented an evidence-based healing design: Site visits can help administrators form redesign ideas and obtain implementation tips.
- Involve end user in design decisions: Seek specific input from doctors (in all specialties), nurses, and patients. For example, staff should review design plans to ensure that the configuration maximizes their convenience. The cancer center has conducted many patient and staff surveys on separate topics, including on way-finding and paint colors. Creating a formal patient advisory council can also be helpful in soliciting indepth feedback and recommendations.
- Avoid decisions based on personal taste: Decisions about colors, artwork, fabrics, etc. should be based on what will maximize healing and comfort for patients, not on the personal tastes of the decisionmakers.
- Ensure sufficient bay space if possible: Although a postoccupancy survey confirmed that the redesign does provide a feeling of serenity and safety, patients, caregivers, staff, and doctors expressed the opinion that the infusion bays should have been larger. Because of the high demand for more treatment stations and the considerable space restraint even with the expansion project, a decision was made to go with a smaller size than would have been ideal. As a result, visitor chairs are pushed out to accommodate the patient when he or she wants to fully recline. Redesign efforts should attempt to make bays wide enough to place the visitors beside the patient rather than at the patient's feet.
- Develop and thoroughly test models before finalizing architectural plans: Although the cancer center nurses appreciate the beauty and serenity of the new space, they find it difficult to move around in it. Members of the planning team learned that more time should have been spent during the modeling stage of the project. The majority of staff and doctors who will work in that area should practice delivering care in the models with all the equipment they normally use. Patients should not simply look at the models but should actually pretend to use them to see if their needs will be met. For example, it is critical to bring the intravenous poles into the bays to ensure there is enough floor space. Visitor space should also be modeled to ensure that the chairs are comfortable for extended periods of time and that visitors have a table for their belongings and drinks or food.
- Balance nurse proximity with patient comfort: Although it is important for the nurses to be close to the patients, confidentiality concerns have become an issue for those bays immediately across from the nursing station. Cancer center patients have also expressed concern about the noise emanating from the nursing station.
- Consider the (potentially negative) impact of design on patient care: Some design changes might be aesthetically pleasing but can detract from patient comfort or care. For example, the cancer center's high ceilings are uplifting and beautiful, but because heat rises, patients easily become cold. Although individual temperature control units were placed in each bay, they have proven inadequate; as a temporary measure, the center is using a blanket warmer. As another example, the infusion bays' recessed, trendy lighting is insufficient for intravenous starts. As of August 2009, the cancer center is working with the architects and interior designer to adjust the bay lighting, temperature control, and nursing station noise.
Sustaining This Innovation
- Continue to innovate: Seek new innovations and improvements by conducting ongoing patient and staff surveys centered on specific targets for redesign.
Contact the InnovatorMary Lue Henderson, FMA
Senior Administrative Services Associate
Cedars-Sinai Medical Center
Samuel Oschin Cancer Center
8700 Beverly Boulevard
Los Angeles, CA 90048
Innovator DisclosuresMs. Hendersen has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesFouts M, Gabay D. Healing through evidence-based design. Oncology Issues. 2008 May/June;28-32. Available at: http://accc-cancer.org/oncology_issues/articles/mayjune08/fouts.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
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/professionals/systems/hospital/transform/transform.pdf.
Designing the consumer-focused facility: aligning facility design with market preferences. Washington, DC: The Advisory Board Company; 2007.
Stichler J. Using evidence-based design to improve outcomes. J Nurs Adm. 2007;37(1):1-4. [PubMed]
(added February 2013) Silvis JK. Patient-Centered Design: Proving The Payoff. 2013 Jan 30. Available at: http://www.healthcaredesignmagazine.com/blogs/jennifer-kovacs-silvis/patient-centered-design-proving-payoff?spMailingID=41002721&spUserID=NzYwMTIzNzk0S0&spJobID=177862976&spReportId=MTc3ODYyOTc2S0
Clancy CM. Designing for safety: evidence-based design and hospitals. Am J Med Qual. 2008;23(1):66-9. [PubMed]
Rollins JA. Evidence-based hospital design improves health care outcomes for patients, families, and staff. Pediatr Nurs. 2004;30(4):338-9. [PubMed]
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Original publication: December 09, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 18, 2013.
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