Despite deep and vocal disagreements over healthcare reform, virtually everyone believes that the current system is not economically sustainable. We are spending too much and getting too little in return. This recognition has spurred healthcare leaders to examine every aspect of hospital operations. But what about the healthcare building itself, the physical environment within which patient care occurs? Too often, cost-cutting discussions have overlooked the hospital structure. Changes in the physical facility provide real opportunities for improving patient and worker safety and quality while reducing operating costs.

The “Fable” hospital, an imaginary amalgam of the best design innovations that had been implemented and measured by leading organizations, was an early attempt to analyze the economic impact of designing and building an optimal hospital facility. The Fable analysis, published in 2004, showed that carefully selected design innovations, though they may cost more initially, could return the incremental investment in one year by reducing operating costs and increasing revenues. Reactions to the Fable paper varied. Many felt it presented a compelling case and stimulated healthcare leaders and architects to think differently about balancing one-time building costs with ongoing operating costs. Others voiced skepticism about whether the benefits were as great as described and asked for more evidence.

Today, the Fable hospital is no longer imaginary. During the past six years, numerous hospitals have implemented many of its attributes and have evaluated their impact on patients, families, and staff. Several are members of The Center for Health Design's Pebble Project, a group of organizations that apply evidence-based designs to improve quality and financial performance. Two Pebble hospitals-Dublin Methodist Hospital and Sacred Heart Medical Center at RiverBend-are featured in essays accompanying the complete version of this article in The Hastings Center Report.

These and other pioneering organizations and their architecture/design teams are introducing such interventions as larger single-patient rooms, which reduce the incidence of healthcare-associated infections; wider bathroom doors, which reduce patient falls; HEPA filtration and other indoor air quality improvements, which reduce healthcare-associated infections; appropriate task lighting in medication dispensing areas, which reduces medication-related errors; hydraulic ceiling lifts in patient rooms and bathrooms, which reduce patient and staff lift injuries; and art and music, which reduce anxiety and depression, and speed recovery.

Since 2004, much has changed that affects decision-making about healthcare construction and design. It is time for a fresh look at the Fable hospital. Drawing on the latest design and healthcare knowledge, research, the 2010 health reform law's emphasis on value and quality improvement, and our collective experience, we present Fable hospital 2.0.

The changing healthcare landscape

Five major healthcare trends are relevant to our analysis: the growth of evidence-based design, the safety/quality revolution, pay for performance and increasing consumer transparency, sustainability and green design, and access to capital.

The growth of evidence-based design. The Center for Health Design's definition of evidence-based design is “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” That evidence is much more abundant. In 1998, a review found fewer than 100 solid studies. A 2004 analysis found more than 600 worthy studies.4 In 2008, a team found 1,200 methodologically sound studies.

Facility design guided by credible research has become the standard for architects and designers, as witnessed by conferences focused on evidence-based design and the appearance of new publications.6 More than 500 healthcare and design professionals have been accredited by The Center's Evidence-Based Design Accreditation and Certification program, which was launched in 2009. Although the growth of evidence-based design has provided considerable guidance, other evidence comes from management, finance, computer science, human resources, ergonomics, supply chain distribution, and conservation.

The safety/quality revolution. Two landmark Institute of Medicine (IOM) reports, “To Err is Human” and “Crossing the Quality Chasm,” documented that thousands of patients were dying unnecessarily in American hospitals and presented powerful recommendations for reducing that number, sparking a widespread reexamination of care processes. In addition, the 2010 health reform law provides for developing a national quality improvement strategy. The safety/quality movement has also been stimulated by some collaborations led by the Institute for Healthcare Improvement. The 100,000 Lives Campaign and the Protecting 5 Million Lives from Harm Campaign mobilized more than 4,000 hospitals to implement changes designed to reduce events that harm patients. Evidence-based design helps hospitals pursue the quality goals contained in the IOM reports. When combined with process improvements and cultural change, it can measurably enhance an organization's safety and quality goals.

Pay for performance and increasing transparency. Payers are no longer willing to pay for poor performance. They are adopting a new concept, called value-based purchasing or pay for performance, in which payment is based on performance or quality measures. Under the health reform law, Medicare is scheduled to adopt a pay for performance approach beginning in 2012. This new payment system will have a profound impact on the business case for quality improvement.

The Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum have identified a list of “never events,” errors that are largely preventable and should never occur in hospitals. Medicare will no longer reimburse for the incremental costs incurred by certain preventable errors. Medicaid and commercial payers are beginning to follow suit. It seems reasonable to assume that within three years, few payers will reimburse hospitals and physicians for the costs of preventable harm. Building designs that help reduce preventable harm are becoming key elements in a hospital's survival strategy.

In this age of transparency, patients increasingly have access to hospital performance data concerning patient outcomes and service quality. Since October 1, 2008, the CMS has required hospitals to give all Medicare patients the opportunity to complete a survey (Healthcare Attitude and Patient Perception Survey) about their care experience. Hospitals that are safe, pleasing, and comfortable are likely to be rated high by patients, potentially influencing hospital choice, market share, and bottom-line results. In addition to specific questions about noise and cleanliness, the survey concludes with a “willingness to recommend,” the response to which is likely to be influenced by the hospital environment.

Sustainability and green design. Environmentally sensitive design strategies are becoming standard practices in healthcare organizations, leading them to improve the health and safety of building users, reduce operating costs, and demonstrate corporate social responsibility. In a 2007 survey of healthcare leaders planning capital projects, 90% said they were incorporating or planning to incorporate green concepts despite the perception of higher capital costs-clearly indicating that sustainable design has become integral to this generation of healthcare construction. Capital cost premiums related to green design strategies differ among projects. In one survey, the incremental costs ranged from zero to 5%.

The benefits of sustainable design include improved indoor air quality, reduced consumption of energy an
d potable water, and staff satisfaction and retention. Energy efficiency is generally the first place that healthcare executives look for a measurable return on investment. In the 2007 survey, leaders of 13 projects certified by LEED, a green building certification program, predicted average annual energy demand reductions of 22%.

A limited but growing body of evidence links indoor air quality to health status. Measures to reduce indoor pollutants include the use of paints, adhesives, and other materials that emit little or no volatile organic chemicals like formaldehyde. These measures are becoming mainstream and cost-competitive.

Access to capital. It is an overriding tenet of capital investment in building projects that demonstrating financial sustainability with economic and investment returns sufficient to pay capital providers will generate access to more capital. Health systems with successful economic models will be operating hospitals whose building and care delivery processes are designed with a focus on quality, coordinated care, patient and employee safety, and economic sustainability.

Creating Fable 2.0

Like its predecessor, the Fable 2.0 hospital is an imaginary facility located in a medium-sized American city. It is a new three-hundred-bed regional medical center built to replace a 50-year-old institution. Fable 2.0 provides a comprehensive range of inpatient and ambulatory services. It is located on a donated urban site, so the cost of the land is not included in the calculations.

Fable 2.0 is approximately 600,000 square feet (2,000 square feet per bed) and costs $350 million to construct. Construction costs have increased substantially since 2004. According to Turner Construction, the average cost per square foot in an average city has more than doubled, from between $170 and $185 per square foot to approximately $450 per square foot today. While construction costs in some areas are significantly higher or lower, we chose $450 per square foot as our baseline.

Fable hospital's leadership promotes superior clinical quality, safety, patient-focused care, family friendliness, staff support, efficiency, community responsibility, and ecological sustainability. Reflecting the latter goal, Fable 2.0 decided to achieve a sustainable building that met LEED's gold-certified level using a range of construction and operational initiatives. Management engaged an experienced interdisciplinary healthcare design and construction team that was philosophically aligned with the organization's culture and values. The hospital board, medical staff, and management were actively involved in discussions about evidence-based design and its impact on ongoing operating costs.14 The premium associated with the proposed innovations for the original Fable hospital was approximately 5% of total construction costs. For Fable 2.0, the premium was estimated to be 7.2% because of a longer list of evidence-based features, and approximately 8.4% when the list included design features that look promising but are not backed by research-based evidence.

The payback for the Fable 2.0 investment should occur within three years, longer than the one year estimated for the original Fable hospital but still a reasonable return by any business standard. A primary factor in the longer payback period is that our financial calculations no longer include increased revenue projections. We continue to believe that design innovations will often bring important economic benefits, but there is enough variability to make average revenue estimates unreliable. We also believe that some hospitals that incorporate evidence-based design features will secure additional philanthropy. In Fable 2.0, we have been even more conservative in ascribing cost savings to evidence-based environmental design because, to be effective, design interventions must be part of a bundle of proven process improvements and cultural change.

Evidence-based innovations

We have organized recommended design innovations into two categories. The first, set out below, are supported by research in peer-reviewed journals. The second includes innovations that are supported by experience but not yet deemed evidence-based (see the full paper for this list).

Larger single rooms. Single-patient rooms are the most effective intervention and, as recommended by the Facility Guidelines Institute, have become the standard in most newly constructed or renovated hospitals. Single-patient rooms improve clinical outcomes by reducing hospital-acquired infections, adverse drug events, and falls. They also improve patient satisfaction. Increasing room size by 100 square feet allows family members to stay overnight with the patient, increasing their satisfaction and involvement in care.

Acuity-adaptable rooms. Hendrich and colleagues were among the first to present evidence that transferring patients from one level of care acuity to another can contribute to medical errors. While including infrastructure for monitoring equipment in patient rooms increases construction costs, it decreases transfers. Reducing patient transfers avoids diagnostic and treatment service delays, reduces medication errors and patient falls, reduces staff work load, and increases patient satisfaction.

Larger windows. Increasing window size can increase light and enlarge views. Natural light and nature views are calming and instrumental in patient recovery and improved outcomes. The calming effect also benefits hospital staff.

Larger patient bathrooms with double-door access. Many patient falls occur between the bed and the bathroom or in the bathroom itself. Enlarging patient bathrooms and widening bathroom doors help staff or family members assist patients moving to and from the bed and the bathroom.

Ceiling-mounted patient lifts. Hospital staff experience a high rate of musculoskeletal injuries caused by lifting patients in and out of bed or a bathroom. Patient lifts are relatively new and are connected to the ceiling over the bed and extend into the bathroom. Using ceiling lifts reduces staff back injuries, staff sick time, and hospital costs.

Enhanced indoor air quality. HEPA filtration is 99.97% effective in removing harmful particulates to reduce healthcare-associated infections. Infections can be reduced further if outside air is exhausted after a single use, rather than recirculated, as is standard in American hospitals today. In Fable 2.0, all of the air is exhausted after a single use.

Decentralized nursing substations. Traditionally, hospitals were designed with one centralized nurse station per floor, but Fable 2.0 has decentralized stations, allowing nurses to see into the patients' rooms and respond to problems more quickly. Decentralized stations help reduce patient falls and allow nurses to spend more time in direct patient care.

Hand-hygiene facilities. Hand hygiene is the most important measure for preventing the spread of pathogens. Convenient access to sinks in all patient rooms and other points of care helps increase hand washing compliance.

Medication task area lighting. Medication dispensing errors are reduced when lighting is improved because clinicians can read medication labels and prescriptions more accurately. Considerable research has shown that performance and errors are affected by lighting levels.

Noise-reducing measures. Noise is a common problem for patients and staff, causing patients sleep deprivation, slower recovery, and increased stress. Fable 2.0 uses multiple strategies to quiet the building, including high-performance sound-absorbing acoustical ceiling tiles, carpeting where possible, sound-absorbing finishes, noise and vibration-isolated mechanical rooms, wireless pagers, space for private discussion, reduced alarm sounds, and single-patient rooms.

Energy demand reduction. Reducing fossil fuel use save
s operating dollars, cuts carbon emissions, and lowers airborne emissions linked to community health problems (such as asthma). Energy demand is reduced through a high-efficiency building envelope and glazing, high-efficiency mechanical equipment, and heat recovery systems.

Water demand reduction. As large water consumers, hospitals save money by implementing measures like low-flow fixtures, rainwater capture, and high-efficiency food service equipment. Water conservation measures do not include replacing hand-washing sinks with alcohol-gel alternatives, as water is often necessary to remove dirt from hands.

Electronic Intensive Care Unit. The e-ICU system is a remote, high-tech surveillance system, providing electronic real-time connections to hospital ICUs. Using this system, which includes vital sign indicators and visual monitoring capabilities, physicians monitor the condition of multiple patients and communicate efficiently with staff, patients, and family. The use of e-ICU has reduced mortality rates, shortened the average ICU stay, and reduced costs.

Healing art. Certain types of artwork in public and patient care areas can improve patient health outcomes. Art that depicts calming views of nature can reduce anxiety and depression and speed recovery.

Positive distraction measures. Distraction can play an integral role in the patient healing process. In addition to art, calming music in patients' rooms and procedure areas can speed recovery and decrease patients' pain, length of stay, stress, and depression.

Healing gardens. Well-designed indoor and outdoor gardens reduce stress and improve outcomes by providing positive distraction and restorative nature contact for patients, families, and staff.


The business case for building better facilities is even stronger today than in 2004, when the original Fable hospital was described. The costs of infections, falls, and errors are greater; the number of proven effective design interventions is larger; the willingness of payers to reimburse hospitals for harm they cause is ending; and the expectations of consumers are greater in an environment of increased transparency and ease of comparing outcomes and experiences. In describing Fable 2.0, we were conservative in ascribing economic benefits to evidence-based design improvements. Despite this, Fable 2.0 provides a return on the incremental costs of design within three years. Healthcare leaders, architects, designers, and researchers have a growing body of evidence about how to build better hospitals. Existing healthcare facilities can also undertake high-impact innovations that improve care.

The cost/benefit estimates contained in Fable 2.0 will vary according to the type of patient population and the region of the country. Our objective has been to broaden the conversation from one focused exclusively on capital costs to one that includes balancing capital costs and operating savings. We hope that healthcare and design leaders will strengthen their commitment to building better caring environments. Healthcare is one of the most personal and consequential services that people use. Why shouldn't we use our best available research and experience-based judgments to build a hospital that serves better and costs less to operate? HCD

Blair L. Sadler, JD, is a senior fellow at the Institute for Healthcare Improvement. Leonard L. Berry, PhD, is a distinguished professor of marketing, MB Zale Chair in retailing and marketing leadership, and professor of humanities in medicine at the Mays Business School at Texas A&M University. Robin Geunther, FAIA, LEED AP, EDAC, is a principal at Perkins+Will. D. Kirk Hamilton, FAIA, FACHA, EDAC, is an associate professor of architecture, Texas A&M University, and founding principal of WHR Architects. Frederic Hessler is the managing director, healthcare group, at Citigroup. Clayton Merritt, M. Arch, has a certificate in health systems and design from Texas A&M University and is vice president of Traton Engineering Associates and president of Caliche Creek Investments. Derek Parker, FAIA, RIBA, FACHA, EDAC, is the director emeritus at Anshen+Allen Architects. To read the Fable 2.0 article in full, please visit

Editor's Note: This article is an excerpt from an original article published in January 2011 by The Hastings Center Report and is part of a set of essays on evidence-based design published by The Hastings Center. For a copy of the full article, including references, please visit

Healthcare Design 2011 April;11(4):40-44