A Moratorium on Waiting Rooms, Parking Lots, and Hospitals?

I’ve had lightning strike me twice. Okay, metaphorically speaking.

The first time was about 15 years ago in Utah when I was invited to be the “patient representative” on a hospital committee who had won a huge grant from a foundation. Little did they know what they were getting themselves into by inviting me in! The committee was a diverse group of two doctors, a nurse, a hospital administrator, a social worker, an architect, a receptionist, and a few others. And me. We met almost every Wednesday afternoon for a year (though I remember feeling like it was seven years, in dog time or something). Our task: to come up with and prioritize proposals for the hospital CEO on how to spend several hundred thousand dollars on something that would “empower patients and make their hospital experience much better.”

For the first few months, we brainstormed well over 100 ideas in some detail which the architect cartooned out for us on paper while I wrote the descriptions in text on my laptop: A scholarship fund to pay for local hotel rooms for families with children in the ICU…An outdoor garden with sculpture, benches, and fountains…Rebuilding the cafeteria and food service (I can attest that this should be a priority, but it didn’t seem a good use of that particular bucket of money!)…Buying artwork and new paint for the patient rooms to make them less dreary….Getting laptops for the doctors (it was their idea!)…Hiring a hospitalist to help coordinate care for people…Installing a new tracking technology to locate patients in the hospital…And many, many, many, oh so many more.

You would think we had been deciding the fate of the entire planet. These sessions were endlessly contentious. There were times I was relieved we were already in a hospital in case one of us passed out from boredom or shot someone else on the committee just to make them shut up. I tried for months to get us to develop a matrix of criteria for rating each idea (I guess it was inevitable that I would end up at Intel one day), but no. We’d just argue each idea out and move on to the next one only after people’s rage or passion had finally been beaten out of them. Six months later…we finally got to a top twenty list with a two-page description for each one. Two more months…a top five list with a detailed budget…but no consensus. So we brought in the CEO to settle the hung jury.

I don’t have the energy to replay that high drama here, though the memory of it is etched in me forever, especially the CEO’s hawk-beak nose, squeaky voice, and propensity to flip his comb-over wisp of hair whenever he was nervous. (And he was nervous a lot in these contentious meetings.) There were four of the five ideas I could be happy with, but the fifth was just terrible: they wanted to improve the waiting rooms with more space, nicer chairs, internet access, and larger television sets. I called this the “couch potato” proposal (which no one else appreciated for some reason). Somehow we got down to couch potato and the public garden, the latter of which I was sure would win.

I made an impassioned plea against the waiting room couch potato plan. “If you build bigger and better waiting rooms, you’ll just increase the wait times even more! Every doctor and nurse and scheduler in this hospital will think to themselves how nice and home-like the waiting rooms are, so why hurry things along?  How are patients going to be empowered by being asked to wait even more than they already do? In fact, let’s spend the money to get rid of all the waiting rooms…just close them and use the space for something else. That way you’ll force yourselves to define an entirely new workflow that doesn’t rely on making people wait!”

Complete and utter silence.

I think they seriously considered having me admitted to the psych unit. Then, the CEO flipped his hair back from left to right, and they voted overwhelmingly to go with the garden, which I should note was basically destroyed after the first winter snows wiped out the fountains and many of the sculptures. (I kid you not: it is now the designated outside smoking area!) There was one silver lining: about a year later, the architect from the committee phoned me up to meet her for lunch. It ends up she had sketched an entire plan for a hospital without waiting rooms (except for the ER) and had thought through what kinds of communications systems and cultural practices would have to happen to make it work. I was overjoyed.

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The second lightning strike was about 6 years ago when I was, once again, put onto a panel of advisors for an Oregon hospital who had decided to build a mega parking lot due to traffic problems on their huge campus. They wanted “patient input” before spending the millions of dollars on the project. It was another bureaucratic drama about rainwater and climate impact, but not nearly as long or interesting as the Utah couch potato experience. Still, a similar unexamined assumption was at the heart of that decision: that spending money on making it easier to be at the hospital is the best use of healthcare resources. No one seemed even prepared to ask: what is the opportunity cost of building a new parking lot over other projects the hospital could have invested in?

Once the land had been acquired and the construction started on the garage, there was no stopping the parking lot juggernaut. While it went more than three times over the initial budget, they put up happy signs of “progress” that adorned the entire hillside as the structure slowly took shape. Massive investments of time, energy, imagination, and money were used to create that gleaming, shining monument to mobility. And what was the result? The hospital administrator confirmed my experience as a patient there. He admitted to me privately that it only increased the parking nightmare on the campus as now more patients come to the hospital because they, ostensibly, have plenty of parking! (And the cost for maintaining and staffing the parking deck has been five times what they anticipated.)

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Maybe it is time to stop building not only waiting rooms or parking lots…but also hospitals. Maybe the 5,708 hospitals currently registered in the United States is more than enough for the next 100 years. So should we declare a moratorium on any future hospital building until we can prove that we really need them? I know, I know…call the psych ward for Dishman again. But if we’re so worried about the high costs of hospitals, then let’s stop making it so easy for people to go to them. And let’s force ourselves to use the ones we have more efficiently and more appropriately. This requires focusing hospitals on emergencies, surgeries, and urgent care instead of the chronic disease management factories and walk-in clinics for the uninsured (who have nowhere else to go) that many hospitals have become.

If we’re going to really do transformational healthcare reform in America, then we need to be ready to rethink things down to the buildings and foundations for care.  If we continue to build more and more expensive hospitals, then we will use them. Humans will creatively jump through any hoop to use and justify what we have already decided to build. We’re perfectly ready to invest time, energy, thought, and even more money to justify our prior decisions and investments, even if they were bad ones. And we will continue to build the things we already know about, understand, and have plans for…because imagining new kinds of care models—and the facilities to support them—is hard.

My hospital friends tell me that the rule-of-thumb for building a new hospital is $1M per bed, so a 500-bed building requires $500M in initial funding. What else could we do with half a billion dollars that would improve the health and wellness of our community? What if we used that money to clean up a local water supply? Or to fund preventive care and screening for everyone in the community? Or what if it was used to build broadband infrastructure and a call center that could help 200,000 people each year care for themselves better from their own homes? What if it was used to help combat obesity by making personal trainers available to everyone in town for free? What would be the return for spending that money to drive better prenatal care or parent education about nutrition for their children?

Crazy ideas—Dishman must have really been hit by lightning. But it is even crazier to continue down an endless path of building hospitals (and waiting rooms and parking lots) at any cost without exploring alternatives to how we might achieve great health for more people. At a minimum, I think we have to begin to rethink what a hospital is. It doesn’t have to be just a physical place—a medical megaplex with mega parking lots and wondrous waiting rooms—but it could become a more holistic care services provider in the community for a wide range of needs beyond emergencies or surgeries. Certainly many hospitals have a trusted brand in their local communities that could allow them to extend far beyond a bricks-and-mortar mission with new services into the home.

Parking lots and waiting rooms, perhaps even the notion of a hospital itself, may be antiquated affordances of a failed medical mission—of a quantity-obsessed, reactive, clinic-centric paradigm that is unaffordable and unsustainable in the midst of a global age wave. We have the potential to reinvent these care buildings and practices to do care a different way and in different locations, if we can just declare a moratorium on unquestioningly continuing with our old ways of thinking. Let’s ask more provocative questions, and see where those crazy answers may take us

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NOTE:  ERIC DISHMAN'S 'HOME BLOG' PAGE HAS MOVED TO:  blogs.intel.com/healthcare.