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Health recordInvest to saveGunnar Öhlén says a whole life costing approach to capital investmentin the global healthcare estate will reap long-term rewardsThe world is full of appropriately planned and well-intended healthcare buildings. But, all too often, as a result of fi nancial compromisesagreed towards the end of the planning process, the fi nal outcome results in a suboptimal building that fails both patients andthe healthcare staff that work there. As head of a large emergency department, less than 10% of my annual budget and that ofthe hospital relates directly to the built environment. Yet, every day, it’s possible to observe how the qualities of our healthcare buildingsnegatively impact on the wellbeing of our patients and staff.In recent years, one of the greatest infl uences on any decisions I have been involved with in relation to new projects and refurbishments,has been an article by Berry et al 1 . Berry discusses the impact and need for additional investments to be made in the hospital environment.In particular, he calls for larger private patients rooms, acuity-adaptable rooms, larger windows and larger patient bathrooms with doubledooraccess, hand-hygiene facilities, decentralised nursing substations, additional HEPA fi lters, family/social spaces on each patient fl oor, ahealth information resource centre, mediation rooms, a staff gym, art for public spaces and patient rooms, and healing gardens.He explains not only the clinical value of these key features, but also theeconomic benefi ts they can bring to the hospital’s bottom line, by reducingpatient transfers, falls, nosocomial infections and the costs associated withdrug delivery.Creating a better working environment also has an infl uence on staffsick leave and turnover. Research at the Karolinska University Hospital byHagerman et al shows that noise-reduction measures have infl uenced thephysiological parameters of cardiac ICU patients as well as staff 2 .All too often, however, fi nancial restraints create suboptimal healthcarebuildings, resulting in an increased operating cost, which ultimatelyrepresents 90% of the overall department and hospital budget. Berry etal suggest another road. By increasing the initial building investment by5% above the baseline to improve the quality of care for patients and theworking environment for staff, operational building costs can be reduceddramatically, providing a payback time on extra initial investment of only6-10 months.In short, there exists a clear choice for those fi nancing our healthcarebuildings. Invest at the outset of a project to decrease the annual running cost of the facility by 5%and, depending on the value of the initial investment, after a number of years you will have savedthe cost of the entire building. Fail to make that investment and, after the same period, you willhave spent the whole building cost again. This is the evidence base upon which capital investmentdecisions in healthcare buildings should be made, but are we doing enough to make this knowledgeavailable and accessible to the bodies that fi nance our healthcare buildings?To play devil’s advocate, it might be argued that the capital investment simply isn’t available tobuild that optimal ten-storey building needed. My answer would be to build nine optimal stories thatin turn will generate the capital for another new optimal building. The alternative is being saddled for40 years with a suboptimal, potentially dangerous ‘white elephant’ building for our patients.Let’s climb the barricades. Let’s raise our voices. Together we can refuse to build healthcarefacilities that are not based on a credible platform of evidence. As Winston Churchill said: “We shapeour buildings and, afterwards, our buildings shape us.”References1. Berry LL. Coile RC Jr, Parker D, Reiling J. Facility Design Focused on Patient Safety/Reply. Frontiers in Health ServiceManagement 2004 (Fall); 21(1):3-24.2. Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA; Theorell T. Infl uence of intensive coronary care acoustics on thequality of care and physiological state of patients. International Journal of Cardiology 2005; 98:267-270.Gunnar Öhlén MD PhD is headof the emergency department(ED) of the Karolinska UniversityHospital and president of theEuropean Society for EmergencyMedicine (EuSEM). This articleis a personal view and does notnecessarily refl ect the positionof EuSEM70 October 2008 | WORLD HEALTH DESIGN