Reducing the third leading cause of death in America.

Currently the number of hospital acquired infections (HAI’s) is about 1 in every 25 to 31 hospital patients admissions. Of those, nearly 100,000 will die as a result of that HAI.

Ever since the Institute of Medicines 1999 report entitled “to error is human” we have known of the staggering number of annual preventable deaths in our hospitals, yet even with additional mitigation measures over the last two decades, our progress in the reduction of that number is dismal.

Consider the 2019 John’s Hopkins report on all preventable hospital deaths, estimating the number to be up to 400,000 per year, making it the third leading cause of death behind Cancer and Cardiac cases.

Healthcare facility Codes standards and guidelines have been increasingly focused on this issue to eliminate the built environment as a causation. However, in our experience the implementation of many of these design elements are marginalized at best, and completely ignored in many cases.

But why?

• Why is something so well known so poorly implemented?

• How do designers, engineers, contractors and vendors miss the target consistently?

• Is the inspection and enforcement component lacking in resources, knowledge or experience to identify these well known, well researched and documented risks?

Today, these preventable events are rarely published beyond a single news cycle and typically only for a celebrity involvement. And even more rarely is the event followed up with documented responses to prevent future events.

What needs to be done in order to dramatically improve outcomes and eliminate preventable deaths?

What if every HAI death was given the same investigative response as the FAA does for airline deaths?
The same scrutiny applied to the investigation, communication and mitigation measures and then prescriptively applied across the board to every hospital in the U.S that has the same potential risk factor.
Would we start seeing a significant decrease?

Could this become a significant financial burden to thousands of healthcare facilities? Probably, but what is the value of those 100,000 lives?

Could preemptive actions before these errors are imbedded into the facility reduce that cost?

Absolutely, the research confirms that to be the case.

We believe there are five fatal flaws in our current delivery process where these issues originate and become imbedded into the healthcare built environment as a latent error. Those flaws exist in the planning, design, construction, activation and operations of all healthcare facilities.

We are hoping to elevate the complex issues with these five fatal flaws so that all stakeholders can understand the comprehensive impacts and make informed decisions to reduce risks, improve outcomes and build efficient and effective healthcare built environments is our driving principal.

As these individual processes are all integrated into a system of systems, focusing on any single component will not resolve the issue. It must be addressed at a higher level with the systems approach.

A chain is only as strong as it’s weakest link, and a healthcare delivery system that has a weak link in the planning, design, construction, activation or operations component will continue to make the same preventable errors, resulting in the above HAI statistic and other preventable outcomes that impacts patients and staff.