Eszter Gulacsy of Mott MacDonald talked to World Health Journal (WHJ) about the need to make our hospitals healthier to improve both the patient experience and workforce quality of life.
Across the globe, many businesses are putting great effort and resource into working environments that are healthier, cleaner, and more comfortable. However, this consideration isn’t a priority for newbuild hospitals. With the focus of new hospital development centred on efficiency and delivery, it’s easy to forget that the main purpose of hospitals is to make people healthier. So how can the hospital of the future be made healthier for the benefit of both workers and patients?
In the anthology series with Mott MacDonald and WHJ looking at developing the hospitals of tomorrow, Eszter Gulacsy, Technical Director for sustainability and healthy buildings at Mott MacDonald, spoke about the steps that are needed to make modern hospitals as healthy as they can be.
The importance of healthy buildings
Improving the patient experience is the core focus of any initiative in the design and development of future hospitals, and creating hospitals as healthy buildings has many additional benefits. The better recovery of patients, less risk of hospital-acquired infections, the ability to attract and retain staff, a more productive and effective workforce, and an improved visitor experience are all goals that can be achieved through healthier buildings.
"In general people spend 90 per cent of their time inside buildings, and this includes healthcare facilities,” says Eszter. “These buildings are the everyday workplaces for medical and non medical staff, and building performance affects their health in the same way as for employees in other types of offices, if not more.”
It has been shown, for instance in Japan, that poor indoor air quality in hospitals, while not the sole cause of adverse health effects, does contribute to poor health and potential long-term problems for employees. US healthcare workers have a disproportionate incidence of asthma and available evidence suggests that exposure to chemicals in cleaning and disinfecting products may contribute to this. Accurate characterisation of exposure to volatile organic compounds (VOCs) is needed.
How can healthy hospitals be developed?
At a fundamental level, new hospital buildings can be made healthier in a similar manner to non-healthcare buildings by incorporating health and wellbeing considerations into the design, integrating them into the construction process and long term operations.
Although the principles are the same, in a healthcare setting the clinical needs have to be carefully considered and evaluated. While the core aspects of healthy buildings revolve around features such as daylight, views, good indoor air quality, acoustic and thermal comfort, this has to be counterbalanced against a hospital’s needs. Some aspects of healthy buildings can take on an even more crucial role in healthcare facilities, such as accessibility, infection control and visitor wayfinding.
Should these principles be mandatory in every design? If you asked any patient or hospital worker whether they would like to have a quiet, well ventilated, adequately heated building with views of nature, plenty of daylight, and ease of access, the answer would be an unequivocal ‘yes’. So why are we not seeing hospitals with this at the forefront of design?
“The reasons these and other similar principles are not incorporated into healthcare design are many such as; an existing building portfolio, short-term financial planning, a difficult to quantify return-on-investment, and to encourage adoption of healthy building design principles as default requires these blockers to be removed first,” says Eszter. “In many cases decision makers are not fully informed about the return on investment of healthy spaces.”
Difficulty within healthcare
In healthcare buildings, an added challenge comes from the more intense use of materials which are not common in the day-to-day work environment. Harsh chemicals, solvents, and cleaning agents, decontamination procedures and dangerous drugs to combat infectious disease, are all hazards that the average employee would not encounter daily. For hospital workers, however, this is not the case.
To eliminate adverse health impacts from these essential and often life-saving materials, the building’s systems need to be designed to remove them swiftly from working environments so that any negative effect is minimised. “Although this may result in an energy penalty, existing healthcare design standards already attempt to strike a balance by prescribing much higher ventilation rates for certain clinical areas, due to the use of various chemical compounds,” says Eszter.
In addition, designing for easy maintenance can result in a reduced requirement for the use of chemical compounds for cleaning, as well as decreasing the potential interactions between different classes of chemicals used in the building. Mitigating the potential impacts of chemical compounds starts with only having those materials in the building that are absolutely necessary. In other words, through pertinent planning potentially harmful compounds can be eliminated from building materials, cleaning agents and other non-clinical aspects of the building, resulting in a reduced exposure for staff, patients and visitors.
Better air, better health, better productivity
Air quality is a major factor in the development of healthy buildings. Poorly ventilated spaces can cause headaches, fatigue, shortness of breath, congestion, and a whole variety of other symptoms. Poor indoor air quality has been the cause of many illnesses worldwide, that in 1984 the WHO described the condition as “sick building syndrome”, or SBS for short, in reference to the ailments caused by and associated with time spent in a building with poor ventilation.
Furthermore, studies have shown that poor environmental quality in buildings can have negative effects on productivity, sometimes to a rate of nearly 10 per cent, as well as increased absences.
Again, it is important to recognise the distinction between low productivity and concentration in an average working environment and a hospital. Low concentration and productivity in a hospital setting may lead to misdiagnosis, malpractice, higher tolerance of drug-seeking behaviour, and perhaps most worryingly, death.
“Most countries in the EU have general requirements in their building codes for adequate air quality, but these requirements in the UK are ‘almost never’ enforced by Building Control. What this means is that at practical completion there is no testing completed to ensure that air quality in the finished building is of an acceptable standard,” says Eszter.
In addition, there is the potential for harmful emissions from building products themselves. Some materials have been part of the manufacturing process for so long that they are very difficult to eliminate, and each year new chemical compounds appear on the market for which long term health impacts have not been established or researched.
“However, where regulation is lacking, the opportunity arises for grass-roots activity to make a change and this is shown in the proliferation of various ecolabels for building products around Europe. These labels are voluntary and very diverse, and can pose a challenge to designers when it comes to choosing ‘healthier’ products, but they have certainly started to change the industry,” Estzer observes.
Considering the cost of healthy buildings
When it comes to the performance of materials which are considered ‘healthy’, this is a constantly evolving market with a continuous stream of new products claiming health benefits. These claims are at times dubious and not necessarily supported by scientific evidence; however, it is obvious that the construction industry is paying increasing attention to the health impacts of building products.
“In terms of cost impact of healthy buildings, it is important to be careful in choosing a baseline against which ‘extra over’ costs are being benchmarked. Often baseline costs are established for a minimally compliant building and compared to that, every enhancement is considered ‘extra over’,” says Eszter.
“In reality, many cost plans do not include items that are essential for every day (not specifically ‘healthy’) operation of the building. For instance, proper handover, commissioning and verification of the building shouldn’t be a health-related extraover item, but may end up being considered as such, if it occurs in the context of a healthy building requirement.”
Improving the patient experience
Ultimately, the goal of developing the hospital of the future is to improve the patient experience. Through innovation, design, air quality control, thermal health, lighting, views, and active design, the hospital of the future will provide an environment attractive to talented clinicians, beneficial to patient interaction, care and experience. Healthcare professionals, hospital staff and visitors will also benefit.
“The importance of a building’s impact on employee and patient health should not be overestimated as it is not more important than work stress, lifestyle and other factors. However, if building performance can contribute to an improvement in concentration and, as a consequence, reduction in mistakes or stress, this can only be good for patient outcomes and experience.”