How to save health care from the pale-green maze

TheGlobeandMail.com – News/National/Focus
Published Friday, Nov. 19, 2010.   Carly Weeks, Belfast

It was on a plane in 1998 that John Cole used his napkin to map out a revolution for Northern Ireland’s health-care system.

Mr. Cole, an executive in Northern Ireland’s Department of Health, Social Services and Public Safety, was on his way home to the outskirts of Belfast after a visit to the Codman Square Health Center, which provides a mix of medical services, classes, counselling and other activities to one of Boston’s poorest and most notorious neighbourhoods.

When the centre first arrived and asked residents what it could do to help improve their lives, they asked that the burned wrecks of cars be hauled away from neighbourhood corners. The gesture helped to inspire community confidence in a new way to think about health care.

Codman Square brought doctors and nurses to patients, taught workers how to prepare their taxes, taught people how to cook better food and gave families a place to swim and teenagers a place to do their homework.

Mr. Cole had been grappling with problems that threatened to engulf Northern Ireland’s health-care system – scarce hospital beds, packed emergency rooms, a shortage of doctors and an aging population with multiple chronic illnesses.

After visiting Boston, he realized that Northern Ireland had been doing things backward: Instead of bringing people to cold, clinical institutions to be fixed after they had become sick, the future would hinge on keeping people out of hospitals.

He was met with a wall of political opposition and skepticism. The health community was hesitant to abandon the traditional hospital model in favour of a focus on prevention and promoting health by designing buildings around the needs of patients.

People were unsettled by the idea of spending vast sums of money to treat outpatients and those needing to enter hospital in an environment that might have more in common with a spa.

Now, as Canada is facing its own health crisis of shortages and rising demand, a growing number of leading authorities say the new Northern Irish system is exactly what is needed here.

It would make patient care a priority by putting everything from doctor’s offices to physiotherapists and speech therapy under one roof and combining them with fitness centres, libraries, financial and legal advisers and meeting spaces for community groups.

These health-and-well-being centres, as they are known, have large, open atriums that make it easy for residents to find their way around, ample natural light, community artwork covering the walls and gardens where visitors can escape for a quiet moment.

What they do not have is beds. In fact, since Mr. Cole’s plan was put in motion, Northern Ireland has begun closing community hospitals to make way for the new centres, where patients can get access to everything they need under one roof.

Those who have chronic illnesses or need continuous care can be visited at home by health-care workers who will help manage their illness. Those who need to be admitted to hospital are sent to a larger regional centre that specializes in their condition.

Although it’s only a few years old, the model is attracting attention from around the world. The new centres have won a slew of prestigious international design awards and delegations from Australia, Japan, Sweden and Norway, among others, have visited to learn from what Mr. Cole has been able to accomplish.

But in Canada, there are fears that unless the health-care rhetoric can move beyond political fighting over budgets and services to focus on how to design a better system, no major improvements will ever be made.

Today’s hospitals are not built for today’s patients

Canadian hospitals are the epitome of contradiction, according to Howard Abrams, the division head of internal medicine at Mount Sinai Hospital in Toronto.

Specialized wings that house cardiology, transplants, neurosurgery and cancer care are often beautiful, state-of-the-art facilities that have no problem playing host to politicians making health-care announcements.

Then there are the general wards, with two or more patients per room separated by thin curtains, as well as an overflow of patients lying on stretchers in hallways and constant noise from visitors, staff and the overhead announcement system.

“If you walk into Princess Margaret [Hospital, one of the world’s top cancer centres], it looks like a five-star hotel,” Dr. Abrams says. “If you walk onto a ward at the Toronto General, for general internal medicine, you feel like you’re in the Third World.”

The problem is that hospitals are generally designed to cater to patients who require acute, episodic care, such as emergency appendix removals, not elderly patients with several complex conditions – even though those patients are taking up an ever-greater number of hospital beds.

“Our hospitals were not designed for the kind of care we need to provide now,” says Dr. Abrams, who is also the executive director of the Centre for Innovation in Complex Care, an organization dedicated to improving care for patients with multiple chronic conditions.

He argues that the health-care system must be reorganized around the needs of Canada’s aging population.

More services need to be offered on an outpatient basis to keep elderly patients active and mobile instead of stuck in a hospital bed for days on end, raising their risk of developing infections or losing the ability to walk.

Patients should have quiet, single rooms to aid in their recovery, with ample natural light to help boost the healing process.

While it might sound like a touchy-feely prescription in the antiseptic, white-coat environment of health care, Dr. Abrams says that if Canada doesn’t adopt these new measures, the crushing demands of future patients will “bring down the health-care system.”

Research estimates that 225,000 patients suffer hospital-acquired infections in Canada each year. Up to 12,000 patients die from those infections annually and the total cost of treating those problems is $1-billion.

A Canadian study published in the American Journal of Infection Control earlier this year found that each hospital roommate a patient has increases his or her chance of developing a life-threatening superbug by 10 per cent, chiefly because they share bathroom facilities.

The study, conducted at Kingston General Hospital, found that hospital patients had two to 46 different roommates during their stays, potentially exposing them to dangerous bacteria.

But changing all that is not an easy task. As it is, ballooning health-care budgets can barely keep pace. It’s difficult for hospital chief executives and politicians to switch gears and adopt a new approach when patients are demanding more doctors and more hospital beds.

“It’s a huge amount of money,” admits Roger Ulrich, a professor of health-facilities design at Texas A&M University who is considered one of the world’s leading voices on what the field calls evidence-based design.

“There’s a real pitfall – and the pitfall is to take a short-sighted view and concentrate on trying to reduce that initial capital investment as much as possible.”

Design it for people, not for bureaucrats

Evidence-based design is the cornerstone of Mr. Cole’s new vision for health care. It means that health facilities are designed around what patients need – not what the health bureaucracy dictates.

It prescribes a bold departure from the typical utilitarian, institutional design of hospitals, with endless corridors, artificial lighting, poor ventilation, excessive noise, shared rooms and maze-like interiors.

In short, hospitals should not be cold, unpleasant buildings that patients dread entering – where they get lost, surrender all privacy, can’t sleep and lose touch with the outside world.

At the Sydenham Court in Belfast, which provides supported living for people with dementia, residents live in domestic settings, sharing household chores, doing their own shopping and making their own meals, with the help of a support worker.

“I’ve always been a very independent person,” Rita Fitzsimmons, a 96-year-old resident, says as she leads a tour of the house she shares with several other residents.

“No matter where you go, it’s not home … [but] it’s just not bad here at all.”

Ms. Fitzsimmons has developed relationships with her housemates in the past three years and has a sense of ownership there. She points out the kitchen as “ours” and proudly shows off her bedroom and the outdoor garden the residents keep.

There is no end to the number of design elements that could improve patients’ experience.

Creating space in rooms for fully reclining chairs or stowed-away cots allows family members or friends to stay with patients overnight.

Separating the elevators used to transport patients from those used by visitors helps to eliminate the spread of germs from patients to the public, and vice versa, allows staff to get around more quickly and helps to preserve patients’ dignity.

Building noise-reducing panels into ceilings and walls can help patients rest. Ventilation systems can be improved to circulate fresh air continuously.

These aren’t just perks. A growing body of data shows that adopting evidence-based design results in shorter hospital stays, faster recoveries and fewer medical errors – a major savings to the health-care system.

A study in the journal Psychosomatic Medicine in 2005 found that post-operative patients placed in rooms with abundant sunlight reported less pain and stress and took 22 per cent less pain medication than those in dim rooms, resulting in cost savings of about 20 per cent.

“The stakes are high in a health-care environment … and it’s very important to get that environment right,” Dr. Ulrich says.

There’s no choice but to find an alternative to the status quo

Some argue that Canada needs to adopt aspects of privatized health care in order to keep the system afloat. Others say the answer is to hire more doctors and health professionals who can attend to more patients.

But the president of the Canadian Medical Association’s answer would look more like the transformation in Northern Ireland.

Jeffrey Turnbull, who assumed the role in August, is also the chief of staff at the Ottawa Hospital, which he said provides him with a unique perspective on the daily struggles of health-care institutions across Canada.

The hospital is 100-per-cent occupied. Staff continually have to decide which surgeries to cancel, since there is not enough capacity to handle them all. Dozens of people are admitted from Emergency every day, but there are no beds for them.

There are also more than 150 people waiting to be admitted into long-term-care facilities who are taking up hospital beds.

These problems are caused by the fact that “hospitals are funded and looked at in isolation,” Dr. Turnball says. “We don’t have a smooth, integrated health-care system.”

He says Canada must embrace patient-focused care and the principles of evidence-based design in order to run more efficiently, provide people with the right kind of care in the right kind of institutions and avoid running up the massive costs that result from people needlessly taking up hospital beds.

“It’s a very, very big part of the overall solution,” he says.

Dr. Abrams, of Toronto’s Mount Sinai, argues that the current system makes it impossible not to look for alternatives.

While it’s clear that private rooms, gardens, noise-reducing materials and other elements add to construction costs, the long-term savings will add up to significantly more, he says.

A few years ago, U.S. researchers used real-world examples to design a fictitious, composite institution called the Fable Hospital. They found that using evidence-based design principles added about $12-million (U.S.) to the total building cost.

But their study, published in the fall 2004 edition of Frontiers of Health Services Management, determined that the extra investment paid for itself in the first year: Reductions in patient falls, infections, drug costs and staff turnover, among other results, produced $11.4-million in savings.

A growing number of facilities across Canada are beginning to embrace evidence-based design principles as part of their redevelopment. The new Royal Jubilee Hospital in Victoria, for example, plans to have nearly 90-per-cent single-patient rooms and to use green, sustainable building practices.

Next year, the Canadian Standards Association will, for the first time, publish sweeping guidelines dealing with all aspects of health-facility design.

Although the organization has published standards dealing with health facilities in the past, this will be more like a “bible” that covers all issues, from standards for minimizing hospital falls and encouraging infection control to guidelines for sustainable building practices.

Ontario is creating a new rule that requires all new hospitals built in the province to have only single-patient rooms.

Alberta’s government released a comprehensive proposal in September that calls for an increased focus on patient care and designing the system around their needs.

Toronto’s Women’s College Hospital is in the process of transforming from a traditional inpatient facility to one that is entirely run on an outpatient basis, emphasizing improved care and flexible access to services.

But to Dr. Abrams and others like him, that is not enough. They say Canadian governments must step up and invest in the changes needed to care for the coming onslaught of elderly patients with chronic health conditions – changes needed to save the system.

“The cost of not addressing this issue will be so high that we won’t be able to do cancer care or transplants or anything else,” Dr. Abrams says.

“We’ll be desperate trying to look after these people.”

Carly Weeks is a reporter for Globe Life.

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