November 20, 2017

For the 'bedless hospital,' the future is now, Harvard professor argues

Daily Briefing

    To "produce more health rather than just deliver more health care," the U.S. health care system must break "the association of hospitals with beds," Neel Shah, an assistant professor at Harvard Medical School and director of the Delivery Decisions Initiative at Ariadne Labs, writes in Politico.

    According to Shah, the health care industry currently tends to equate "patients" and "beds"—but that language, he argues, is a relic "of a very different era."

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    Shah explains that the design of many modern hospitals is "rooted in the sanatoria and asylums of the mid-19th century," where designers sought to "isolate patients" in closed rooms to protect the community.

    But while "convalescing in bed has value for some conditions," Shah emphasizes that "increasingly, we're learning that even relatively short bed confinement can be unhelpful for many patients—and prolonged bedrest can be dangerous at worst."

    But hospitals haven't been reinvented to account for this understanding, Shah contends—although he notes that some hospitals have invested in features that encourage patients to be out of bed, such as walking tracks, trails, and "healing gardens."

    Are hospitals even the right places to treat patients?

    Beyond the question of hospital design, the evolving understanding of "how people get healthier" presents the "broader question of when hospitals are even the right place to get healthier," Shah states.

    He cites several examples of "less bed-focused models of care." For instance, ambulatory surgical centers have become "a strong business model for the growing number of operations for which several days in bed are neither required nor recommended."

    As another example, Shah points to birthing center franchises with rooms that are configured "to encourage the mom to use movement as much as possible to support her labor by literally sidelining the bed."

    Shah also calls for rethinking the default of keeping patients "all closed off." While communicable diseases continue to be a concern, today "the dominant threats to human health—heart disease and cancer, for instance—no longer require isolation." Shah adds that former Surgeon General Vivek Murthy "recently characterized loneliness as the most common 'pathology' he encountered in medical practice."

    According to Shah, one community hospital in Massachusetts opened an early labor lounge for expectant mothers who didn't yet need a labor and delivery room but couldn't be sent home. In the room, women can socialize with their families as well as other expectant mothers "in a relaxing comfortable setting," Shah writes.

    How to make the shift

    Shah acknowledges that "[r]edesigning hospitals isn't an easy job" and "will require culture shifts," as medical practice largely is largely "built around the 'beds' model." That said, hospitals making the shift "may ... get a boost from new payment models" that incentivize population health.

    Shah cites Mount Sinai as an example of a hospital adopting this shift in mindset. The hospital began an ad campaign about two years ago with the slogan, "If our beds are filled, it means we've failed." To help with the shift, an industrial engineer at Mount Sinai has developed an Ambulatory Care Transformation Network to crowdsource better ways for clinicians to provide care. According to Shah, many cases call for working with services near the patient's home instead of providing clinical interventions at the hospital.

    In summary, Shah paraphrases architect Michael Murphy who said "design either hurts or it heals." Shah writes, "The more we know about healing, the more it appears that health care spaces will need a different approach—one that sometimes looks more like a park than a long fluorescent hallway full of beds" (Shah, Politico, 11/8). 

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