Contract - The Impact of the Affordable Care Act on Healthcare Design

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The Impact of the Affordable Care Act on Healthcare Design

29 October, 2013

-By Upali Nanda, Ph.D., Eileen Malone, RN, MSN, and Anjali Joseph, Ph.D.


The impact of the 2010 Patient Protection and Affordable Care Act on healthcare delivery has been widely discussed and debated. But what does it mean for the design industry? In this era of big data, cloud computing, and sophisticated analytical tools, the ability to manage and measure has increased, and healthcare models are changing based on these abilities. With the Affordable Care Act, the onus to manage and measure will be even greater because it will be linked to reimbursement models with strong fiscal implications.

The Affordable Care Act and evidence-based design
Politics aside, the enactment of the Affordable Care Act will transform just about every aspect of healthcare delivery. Sweeping reform legislation targets nine essential components, ranging from access to affordable care to the improvement of patient safety and care quality. One of the fundamental components of the law is the transformation of the reimbursement system. Instead of only paying hospitals based on the volume of care provided, the Affordable Care Act shifts the reimbursement model to one based on care quality.

Hospitals are now financially rewarded for improving the patient experience as measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Beginning in Fiscal Year 2015, through the Hospital Value-Based Purchasing Program of the Centers for Medicare & Medicaid Services (CMS), hospitals will also be reimbursed based on their ability to reduce patient harm as a result of hospital-acquired conditions. Through the use of evidence-based design findings, designers create important solutions that can help to address these pernicious problems.

So, what solutions can designers provide as part of an integrated approach to improve the patient experience, reduce patient harm, and—as a consequence—potentially realize increased CMS reimbursement? There are two items on the HCAHPS’s inpatient survey that pertain to the built environment—noise and cleanliness—both of which can be improved with good design, as noted in the table (below). Key patient safety targets, typically tracked by hospitals, and simple interior design solutions that can help to achieve these targets based on robust evidence and best practice precedents are also listed in the table.

In fact, a large body of evidence indicates that the physical environment impacts many essential healthcare outcomes including patient and staff safety, patient stress and satisfaction, staff effectiveness, the quality of care, sustainability, and healthcare cost. Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical decisions are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment to healthcare outcomes, and is moving toward evidence-based design. The underlying assumption is that the built environment provides the stage for all care delivery, and consequently impacts care delivery outcomes.

Accountability in design
The evidence-based design process relies on using credible research to inform design decisions and then clearly articulating the potential impacts of these design decisions on a broad range of healthcare outcomes. By measuring healthcare outcomes pre- and post-occupancy, and then sharing the results, not only is the team held accountable, but it also contributes to the growing body of knowledge.

Accepted by designers and facilities alike, this accountability is evident in the growing number of hospitals that are part of The Center for Health Design’s Pebble Project, which is committed to measuring, tracking, and sharing outcomes. Design firms with in-house research departments focused on human and organizational outcomes and design and health professionals who are getting their credentialing via Evidence-based Design and Accreditation (EDAC) and Lean Six Sigma training also contribute to accountability.

The EDAC and Lean Six Sigma training allows professionals to become well-aware of the methods to integrate research into design and to then undertake systemic approaches to improve processes based on reduced waste, increased efficiencies, and enhanced collaboration of caregivers.

Emerging trends
How are these initiatives changing what we see in healthcare design today? According to Tom Harvey, FAIA, a senior vice president at HKS, Inc., who is also president of the Center for Advanced Design Research & Evaluation, our industry is in
a position to pose new design hypotheses that stem from what we have learned through evidence-based design research to date. Today’s architects and interior designers need to more aggressively integrate research intent into their design processes and decisions. Some examples of design hypotheses that could contribute to improved HCAHPS scores, as well as other beneficial comparative metrics for clinical outcomes or operational and financial performance, could include the following:

Average size of inpatient units will be reduced, leading to:
 • Increased direct caregiver time spent with patients
 • Decreased distractions and multi-tasking that host opportunity for error
 • Improved caregiver focus by reducing fatigue and distractions
 • Reduced noise levels that will improve environmental ambiance and satisfaction
 • Lower facility operation costs

Medical technology integrated with design will facilitate greater deployment of resources to the bedside, resulting in:
 • Decreased size of inpatient units
 • Increased direct caregiver and family time spent with patients
 • Decreased opportunity for error from distractions and multi-tasking
 • Improved caregiver focus by reducing fatigue and distractions
 • Reduced noise levels that will improve environmental ambiance and satisfaction
 • Improved patient sense of control and overall satisfaction

Information technology will enable new environments that foster greater team collaboration throughout the workplace for healthcare, encouraging:
 • More rapid response to patient needs and inquiries
 • Engagement of a broader caregiving and consulting team
with the patient in real-time
 • Improved, and more consistent, clinical pathways of care to support prudent decision-making that reduces cost of care and increased patient/family responsiveness

In addition, we will see a rise of collaborations between the health sector and the construction and design industry, a trend towards lean construction processes and integrated project delivery teams, and partnerships between academia and industry. This will create a robust and actionable knowledge base to inform cutting-edge design practice.

Affordable Care Act and accountable design

Implementation of the Affordable Care Act provides the design community with a singular opportunity to provide evidence-informed solutions that will help to reshape the healthcare experience. Given the growing need to become analytical and evidence-informed designers, we predict that, in coming years, we will see a broad array of new hypotheses explored. Those projects with successful research findings will emerge as new, validated best practices. Today, we are at the cusp of a wave of change, and many challenges lie ahead for healthcare organizations as they undertake quality improvements.

The built environment is an essential component in an integrated bundle of solutions to improve care and maximize reimbursements. Success depends on the early engagement of the design team so that it can discuss with owners the impact of design decisions on healthcare outcomes, using a lifecycle rather than a first-cost investment approach. A collaborative approach—with shared accountability, a commitment to improved outcomes, open dialogue, and interdisciplinary and informed teams—will lead this new era of affordable care and accountable design.

Upali Nanda, Ph.D., is vice president and director of research at HKS, Inc. in Houston. Eileen Malone, RN, MSN, is a senior partner at Mercury Healthcare Consulting in Alexandria, Virginia. Anjali Joseph, Ph.D., is vice president and director of research at The Center for Health Design.




The Impact of the Affordable Care Act on Healthcare Design

29 October, 2013


The impact of the 2010 Patient Protection and Affordable Care Act on healthcare delivery has been widely discussed and debated. But what does it mean for the design industry? In this era of big data, cloud computing, and sophisticated analytical tools, the ability to manage and measure has increased, and healthcare models are changing based on these abilities. With the Affordable Care Act, the onus to manage and measure will be even greater because it will be linked to reimbursement models with strong fiscal implications.

The Affordable Care Act and evidence-based design
Politics aside, the enactment of the Affordable Care Act will transform just about every aspect of healthcare delivery. Sweeping reform legislation targets nine essential components, ranging from access to affordable care to the improvement of patient safety and care quality. One of the fundamental components of the law is the transformation of the reimbursement system. Instead of only paying hospitals based on the volume of care provided, the Affordable Care Act shifts the reimbursement model to one based on care quality.

Hospitals are now financially rewarded for improving the patient experience as measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Beginning in Fiscal Year 2015, through the Hospital Value-Based Purchasing Program of the Centers for Medicare & Medicaid Services (CMS), hospitals will also be reimbursed based on their ability to reduce patient harm as a result of hospital-acquired conditions. Through the use of evidence-based design findings, designers create important solutions that can help to address these pernicious problems.

So, what solutions can designers provide as part of an integrated approach to improve the patient experience, reduce patient harm, and—as a consequence—potentially realize increased CMS reimbursement? There are two items on the HCAHPS’s inpatient survey that pertain to the built environment—noise and cleanliness—both of which can be improved with good design, as noted in the table (below). Key patient safety targets, typically tracked by hospitals, and simple interior design solutions that can help to achieve these targets based on robust evidence and best practice precedents are also listed in the table.

In fact, a large body of evidence indicates that the physical environment impacts many essential healthcare outcomes including patient and staff safety, patient stress and satisfaction, staff effectiveness, the quality of care, sustainability, and healthcare cost. Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical decisions are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment to healthcare outcomes, and is moving toward evidence-based design. The underlying assumption is that the built environment provides the stage for all care delivery, and consequently impacts care delivery outcomes.

Accountability in design
The evidence-based design process relies on using credible research to inform design decisions and then clearly articulating the potential impacts of these design decisions on a broad range of healthcare outcomes. By measuring healthcare outcomes pre- and post-occupancy, and then sharing the results, not only is the team held accountable, but it also contributes to the growing body of knowledge.

Accepted by designers and facilities alike, this accountability is evident in the growing number of hospitals that are part of The Center for Health Design’s Pebble Project, which is committed to measuring, tracking, and sharing outcomes. Design firms with in-house research departments focused on human and organizational outcomes and design and health professionals who are getting their credentialing via Evidence-based Design and Accreditation (EDAC) and Lean Six Sigma training also contribute to accountability.

The EDAC and Lean Six Sigma training allows professionals to become well-aware of the methods to integrate research into design and to then undertake systemic approaches to improve processes based on reduced waste, increased efficiencies, and enhanced collaboration of caregivers.

Emerging trends
How are these initiatives changing what we see in healthcare design today? According to Tom Harvey, FAIA, a senior vice president at HKS, Inc., who is also president of the Center for Advanced Design Research & Evaluation, our industry is in
a position to pose new design hypotheses that stem from what we have learned through evidence-based design research to date. Today’s architects and interior designers need to more aggressively integrate research intent into their design processes and decisions. Some examples of design hypotheses that could contribute to improved HCAHPS scores, as well as other beneficial comparative metrics for clinical outcomes or operational and financial performance, could include the following:

Average size of inpatient units will be reduced, leading to:
 • Increased direct caregiver time spent with patients
 • Decreased distractions and multi-tasking that host opportunity for error
 • Improved caregiver focus by reducing fatigue and distractions
 • Reduced noise levels that will improve environmental ambiance and satisfaction
 • Lower facility operation costs

Medical technology integrated with design will facilitate greater deployment of resources to the bedside, resulting in:
 • Decreased size of inpatient units
 • Increased direct caregiver and family time spent with patients
 • Decreased opportunity for error from distractions and multi-tasking
 • Improved caregiver focus by reducing fatigue and distractions
 • Reduced noise levels that will improve environmental ambiance and satisfaction
 • Improved patient sense of control and overall satisfaction

Information technology will enable new environments that foster greater team collaboration throughout the workplace for healthcare, encouraging:
 • More rapid response to patient needs and inquiries
 • Engagement of a broader caregiving and consulting team
with the patient in real-time
 • Improved, and more consistent, clinical pathways of care to support prudent decision-making that reduces cost of care and increased patient/family responsiveness

In addition, we will see a rise of collaborations between the health sector and the construction and design industry, a trend towards lean construction processes and integrated project delivery teams, and partnerships between academia and industry. This will create a robust and actionable knowledge base to inform cutting-edge design practice.

Affordable Care Act and accountable design

Implementation of the Affordable Care Act provides the design community with a singular opportunity to provide evidence-informed solutions that will help to reshape the healthcare experience. Given the growing need to become analytical and evidence-informed designers, we predict that, in coming years, we will see a broad array of new hypotheses explored. Those projects with successful research findings will emerge as new, validated best practices. Today, we are at the cusp of a wave of change, and many challenges lie ahead for healthcare organizations as they undertake quality improvements.

The built environment is an essential component in an integrated bundle of solutions to improve care and maximize reimbursements. Success depends on the early engagement of the design team so that it can discuss with owners the impact of design decisions on healthcare outcomes, using a lifecycle rather than a first-cost investment approach. A collaborative approach—with shared accountability, a commitment to improved outcomes, open dialogue, and interdisciplinary and informed teams—will lead this new era of affordable care and accountable design.

Upali Nanda, Ph.D., is vice president and director of research at HKS, Inc. in Houston. Eileen Malone, RN, MSN, is a senior partner at Mercury Healthcare Consulting in Alexandria, Virginia. Anjali Joseph, Ph.D., is vice president and director of research at The Center for Health Design.

 


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