Impacts of the Affordable Care Act on Hospital Design

The recent U.S. Supreme Court decision to uphold a critical portion of the Affordable Care Act (ACA) was a watershed moment that will impact the economy, insurance cost and more. It is clear that the ACA will significantly change the healthcare industry, and, in turn, healthcare buildings.

The impact of the ACA on healthcare is an extensive topic, touching many areas of the industry. Having worked almost exclusively on healthcare facilities for the past several years, I have seen some of the changes prompted by the ACA, including the push towards satellite ambulatory facilities and the increased focus on wellness and preventive care. As hospitals become more certain of the future of the ACA there will likely be even more changes made to provide suitable care within the new system. While the majority of the ACA requires changes to hospital structure, paperwork and insurance requirements, some of the mandates in the act relate to specifics of the built environment. Hospitals are now accountable for hospital-acquired conditions, including healthcare-associated infections (HAIs), enforced by reduced payments from Medicare and state Medicaid programs. If a hospital falls within the top 25% of poor performers with certain common or high cost HAIs, payments are reduced by 1%. While the hospital is responsible for infections and errors, building materials and design as they relate to infection control measures can help to reduce risk. In addition to increased responsibility for HAIs, hospitals are also now accountable for patient perception of their environment and care. Financial incentives are tied to hospital performance as measured by a patient satisfaction survey, which includes questions relating to the perceived cleanliness and quietness of the hospital. Though architects cannot control how occupants use the buildings we design, we can consider elements like clean-ability, sound absorption and workplace environment when designing hospitals.

Satellite Facilities and Preventive Care
Healthcare costs in the U.S. have been increasing rapidly. Because the ACA sets limits on the amount that can be charged, and to keep people out of high cost acute-care hospitals and urgent care facilities, numerous hospitals are turning their efforts to wellness and prevention. Leaders in preventive medicine are bringing wellness programs directly to the populations that they serve. To accommodate the many newly insured, they are focusing their construction dollars on satellite facilities that offer a myriad of outpatient services to their communities. These new satellite facilities also provide hospitals the opportunity to offer new technology and equipment, such as robotic surgery, that may not be accommodated in their older facilities.

Healthcare-associated Infections (HAIs)
Apart from new facilities, healthcare providers are also looking to the internal operations of the hospital, as they seek to adjust to the ACA mandates. To limit the occurrence of HAIs, infection control measures are taking a more prominent role. Additionally, innovative building materials that fight infection causing pathogens at the point of exposure have begun to emerge in response to stricter infection control requirements encouraged by the ACA’s reimbursement plan. Recent scientific advances have produced a host of antimicrobial products, including antimicrobial copper and ultraviolet germicidal irradiation (UVGI), shown to kill some of the deadly superbugs that plague hospitals. In addition to these measures, hospitals are also still relying on harsh chemical cleaning to eliminate harmful pathogens. Design consideration for how floors, walls and the like will stand up to bleach washes and repeated exposure to alcohol-based hand sanitizers is incredibly important to prevent premature renovations and save money for healthcare facilities.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Patient perception of their hospital experience is now also being emphasized. The HCAHPS Survey, which is sent to adult patients after their discharge, covers a range of patient satisfaction measures and provides data for effective comparison across acute-care hospitals. Survey questions directly address cleanliness and quietness, the perceptions of which can be changed by hospital room appearance and comfort, as shown by recent research. It is apparent that cleanliness is vital within a hospital, but it is important to note that noise is also more than just an annoyance. A study by the World Health Organization recommends noise levels of no more than 30 dBA inside of hospital wards (specifically for sleep disturbance), but most noise levels in hospitals are higher than this suggested value. Specifically in intensive care units, where patients have some of the most critical conditions, noise levels on average range from 50 to 75 dBA, which causes sleep disturbances that may contribute to delirium and disrupted immune function. Designers, engineers and contractors can discuss a sound reduction plan with hospitals early in the design and construction process to ensure that they are designing and building sound-absorbing and masking appropriate to hospital conditions. Detailing, and ultimately building, acoustical barriers and finishes to match these goals may help to improve patient satisfaction, treatment outcomes and staff health.

Design Response
In response to the ACA, designers should discuss revised goals with their clients and seek an appropriate design response. Early discussions may lead to innovation solutions for how to encourage staff to wash their hands more frequently, or where new building materials may be appropriately used or tested. Ultimately, the hope is that both clients and designers alike can work towards a common goal for healthier, cleaner healthcare spaces, where patients are able to recover quickly.

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