green agenda is a multilevel analysis of socioeconomic health impacts at multiple scales, ranging from a building’s occupants to society as a whole. The DQS agenda converges with the green agenda but differs, according to Zimring, in some important ways. Similar to the green agenda, the DQS agenda advances social and economic goals, but it focuses on using design to improve quality and safety outcomes, such as error and infection reduction, staff turnover, length of stay, and patient and family satisfaction. In this agenda, design is viewed as a tool that can affect healthcare outcomes for patients, staff, and the institution as a whole.

Relationship Between the Two Agendas

The green agenda is based on the notion of a virtuous cycle explained Zimring. Designing, constructing, and managing a hospital in accordance with principles of sustainable development can benefit the local community, the economy, and the environment. It can improve public health as well as reduce the demand for health services.

In contrast, the DQS agenda approaches construction from a slightly different perspective. Similar to evidence-based medicine, in which healthcare decisions can be made based on the best evidence about the outcome of those decisions, evidence-based design decisions are based on the best predictions about their outcome, asserted Zimring. Evidence-based design is the conscientious, explicit, and judicious use of current best evidence in making design decisions that advance an organization’s goals. DQS involves a process in which one understands the evidence, makes hypotheses, tests the outcomes, and works back into decision making.

Part of the DQS agenda is based on two Institute of Medicine (IOM) reports: To Err Is Human: Building a Safer Health System (IOM 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM 1999). In To Err Is Human, the IOM extrapolated that as many as 98,000 people die each year from preventable medical errors. Furthermore, there are approximately 2 million hospital-acquired infections in the United States, and as many as 88,000 people die from those infections (CDC, 2000). Zimring observed that even at the lower end of these numbers, more people in the United States die from hospital-acquired preventable adverse events than from other leading causes of death, such as AIDS, breast cancer, and motor vehicle accidents (IOM, 2000).

One of the reasons why these safety problems occur is that the most experienced caregivers in hospitals—nurses—have a very high turnover rate, noted Zimring. Concern about safety, quality, and nursing turnover has contributed to a “quality revolution” and the belief that healthcare institutions can make a dramatic improvement in healthcare quality and safety through better information and strategic action. This initiative is led by such organizations as the Institute for Healthcare Improvement, the Center for Health Design, and others.

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