Four years ago, when officials at St. Alphonsus Regional Medical Center in Boise, Idaho, first laid out plans for a 227-bed patient tower, there was universal agreement on at least one key element of the costly project: Every patient room would be private, a decision that matched a growing trend in an industry intent on boosting customer service and satisfaction.
Once as rare as made-to-order meals and gourmet coffee kiosks in a hospital lobby, private patient rooms such as those at St. Alphonsus are now the rule rather than the exception. Why? There's a simple explanation, says Susan Gibson, vice president of mission services at the 355-bed hospital: It's called convenience, safety and privacy.
Recalling a comment she once heard from another hospital executive, Gibson says, "Suppose you check into a hotel, and they said, `We're glad to have you here, and your roommate and his family are already up in the room.' What would your reaction be?"
"We take people in their most stressful situations, at a time when they most need privacy-both visual and auditory-and we expect them to be satisfied with a `roommate' they don't even know? That way of thinking has changed. We now believe that private rooms are one of the most important things we can offer."
More and more hospitals are following the lead of St. Alphonsus, building gleaming new facilities that resemble high-tech hotels with private rooms that feature a list of once-unheard of amenities, including flat-screen televisions, bedside Internet access, room-service meals and sleeper-sofas for the family. It's also likely that there's a Starbucks kiosk somewhere in the hospital.
As hospital administrators focus on better ways to make patients safer and more comfortable, semiprivate rooms are quickly becoming a healthcare relic, as outdated as house calls and mercury thermometers. Most big construction companies say they haven't built a hospital with semiprivate rooms in the past two or three years.
This shift from semiprivate rooms, triggered by the industry's collective response to a mixture of regulatory issues, safety concerns and patient preference, may soon become more than a trend if controversial new construction guidelines are approved sometime next year.
Putting privacy first
The 125-member Health Guidelines Revision Committee, responsible for deciding how healthcare facilities are built in this nation, has issued a recommendation that future hospitals include only private rooms, a departure that has generated a flurry of controversy. Officials stress that the recommendation is only preliminary, with the final result resting heavily on the outcome of a 90-day comment period that stretches through the end of January 2005.
"Of all the proposed changes, the boldest is the issue of privacy (and the guidelines mandating all-single rooms)," says Joseph Sprague, chairman of the revision committee and senior vice president and director of health facilities at Dallas-based HKS, one of the nation's largest healthcare-architectural firms. "This is something that has been driven by the industry. I haven't designed a hospital with anything but private rooms in the last three to five years," Sprague says. "But should we mandate it as a society? That's the big question."
Sprague says there are distinct advantages to private rooms aside from the convenience they offer patients. Those benefits include compliance with the strict patient-privacy mandates contained in the Health Insurance Portability and Accountability Act.
"There is no way to meet HIPAA requirements with a multiple-bed room," he says.
While private rooms tend to boost customer satisfaction along with safety-including a reduction in infections and fewer falls by patients-not everyone is convinced that the committee will follow through on the preliminary recommendation, which now states: "Unless the functional program demonstrates the value of a multiple-bed arrangement, the maximum number of beds per room shall be one."
Similar proposals in the past have all ultimately been rejected, most recently about three years ago, primarily because of concerns about costs, says Scott Rawlings, vice president of healthcare at RTKL Associates and a board member of the American Institute of Architects' Academy of Architecture for Health, which works closely with the committee. Even though the wording of the recommendation leaves a lot of wiggle room, depending on how systems define the "value" of a multiple-bed arrangement, some observers predict it will also fail to win approval.
"The proposal is growing in strength," says Rawlings, whose company is also a major player in healthcare architecture. "But it's always been struck down. We've had very heated debates on it. But I can't imagine the committee going forward with this recommendation. I think what will wind up happening is that the guidelines will end up stating that new hospital construction should have all-private rooms rather than shall have all private rooms."
Sprague's committee-which includes architects, contractors, engineers, facility managers, hospital administrators, physicians and other clinicians, among other groups with a stake in the issue-is part of an ever-evolving effort organized by the AIA and the Facilities Guidelines Institute, a not-for-profit Washington-based group that funds the reviews of construction policies on a regular basis to determine the best, most up-to-date ways to build and outfit U.S. hospitals. Sometime next year, the committee will approve a new publication to replace the last set of guidelines, developed in 2001. The publication is expected to be available early in 2006.
Sprague says the preliminary recommendation for all-private rooms is gaining more adherents. Though some experts suggest that having only private rooms adds 10% to 15% to the construction costs of a hospital, Sprague says studies have shown that this configuration saves costs in the long run by increasing operating efficiency, boosting occupancy levels and lowering both infection rates and lengths of stay.
"You have costs factors (for) operations and for capital costs," Sprague says. "I'm not sure the total bottom line does cost any more when you factor all these in."
Officials with the committee stress that no decision will be made for several months on the proposal.
Questions of cost
But the principal concern, especially among small and rural hospitals, remains the increased costs on the front end for all new-hospital construction.
"It's definitely a controversial decision, but the decision hasn't been reached yet," says Dale Woodin, deputy executive director of the American Society for Healthcare Engineering, part of the American Hospital Association. "I think there's going to be a lot of public discussion on this issue. The biggest issue is cost per square foot. Can an organization afford that kind of cost? That's the big question. There are strong feelings on both sides."
A comprehensive study released in November 2003 on this trend found that occupancy rates reach an average of about 80% to 85% for semiprivate rooms, compared to the "ability" of single-bed rooms to reach 100% occupancy. "Even with higher (initial) costs of construction, furniture, maintenance, housekeeping, energy and nursing, single-occupancy can match the per-diem cost of multibed rooms because of higher occupancy rates," according to the study.
One other factor is the cost to patients. While some new hospitals, including those in California, have negotiated higher rates with insurers to cover the increased charges to patients, many others still must add a surcharge for patients who occupy a private room.
Whatever decision is made by the committee, the final result is certain to make waves in a healthcare industry expected to spend more than $12 billion for construction projects in 2004 and as much as $20 billion annually by the end of this decade.
The committee's draft document has been available online since Nov. 1 (at www.aia.org/aah_gd_hospcons03012), with all proposed changes clearly marked by shaded text. Officials expect to receive hundreds, if not thousands, of responses to those revisions during the comment period that extends through Jan. 31, says Sprague, who has been involved in designing healthcare facilities for 35 years. The committee is adapting its 2001 edition of a 176-page publication called Guidelines for Design and Construction of Hospital and Healthcare Facilities, a key tool used in at least 42 states to ensure quality and safety in these building projects.
Construction specifications created by the committee are widely used as a guideline or a point of reference by state officials and the Joint Commission on Accreditation of Healthcare Organizations. The U.S. Housing and Urban Development Department uses the guidelines for participation in a federal loan plan. He says officials view these guidelines as a "rough code" that does not carry the full weight of law but is closely followed just the same. "They are guidelines," he says. "They're as set in stone as the ruling jurisdiction wants to consider them."
Gina Pugliese, vice president of the Premier Safety Institute, affiliated with Premier hospital alliance, says the guidelines have "all but become law" because so many states and the nation's hospital-accreditation organization have decided to follow them. "Once the Joint Commission picked these up as minimums it became the way everyone does things," she says, "and you wouldn't do it any other way."
She says she suspects that the preliminary guidelines that call for all-private rooms will either "be dropped completely or you'll end up with suggestions that a certain percentage of the rooms be private."
Although the guidelines are not written as "code standards" that require compliance, Woodin says, the majority of states use them as a model for healthcare construction. In addition to the issue of private rooms, the committee has considered scores of other changes in the guidelines, including environmental aspects such as the location of electrical ventilation and "green building" designs. But the issue of private rooms remains foremost on the minds of most observers this year.
Sprague says the wording of the proposed guideline now allows plenty of leeway for hospital officials to use costs as a way of justifying a plan that includes at least a portion of semiprivate rooms in their new-hospital construction.
Rawlings, the RTKL executive, says almost all hospital administrators and practicing architects acknowledge that "It's better to go to all private rooms." The issue, he says, is the cost of adding about 25% more square footage to the hospital to accommodate these private rooms, which typically are about 270 square feet per room, including the bathroom. While costs vary depending on location, the outlay for a new hospital averages about $225 per square foot, Rawlings says.
"We all know everybody wants private rooms," he says. "The question is: Should it be required? If you mandate it, you're going to pin some hospitals with a financial or operational issue that could be very, very tough."