What Is a World-Class Medical Facility?
Kenneth W. Kizer, MD, MPH1
The term world class is often used in service and retail
industries, athletic competition, and other non-health care
settings to describe exceptionally good service or outstanding
performance. Being characterized as world class is a
high distinction accorded to an elite few and is generally
taken to mean that one has achieved a level of performance
excellence that ranks among the very best ill the world.
The term world class has been increasingly used in
health care in recent years, although in most such instances
this has been a self-designation made on the basis of
unspecified criteria. For example, a recent Internet search
of the terms world-class health care and world-class
medical center found more than 100 health care organizations
marketing their services as world class, but very few
offering any specifications to support the claim. Similarly,
in opposing national health care reform legislation, 3 former
presidents of the American Medical Association stated
that "Most Americans live within an hour's drive of a
world-class medical facility,"} but provided no explanation
of what is a world-class medical facility. Likewise, in
describing the Joint Pathology Center that will replace
the famed Armed Forces Institute of Pathology, the
Department of Defense states that it will be a worldclass
institution.f-' but provides no functional explanation
of what this means.
Defining World-Class Medical Facility
Care for military personnel located in and around the
nation's capital has long been provided by the Walter
Reed Army Medical Center and the National Naval Medical
Center. In 2005, the Base Realignment and Closure
Commission (BRAC) mandated consolidation of these
2 institutions into a new Walter Reed National Military
Medical Center that would be constructed on the grounds
of the National Naval Medical Center in Bethesda,
Maryland.' This new medical facility is intended to provide
a continuum of primary to tertiary care for active duty
and retired military personnel and their families living in
the National Capital Region (NCR}-the geographic area
that includes Washington, DC, adjoining areas of Virginia
and Maryland, and portions of West Virginia, New Jersey,
and Pennsylvania-as well as comprehensive care for
wounded military personnel returning from combat
overseas.
In authorizing funding for the new Walter Reed
National Military Medical Center and a new military
community hospital at Fort Belvoir in Virginia, the Congress
directed that they be designed and constructed to be
world-class medical facilities+ although no operational
specifications were provided that would ensure accountability
for the use of the appropriated public fundssome
$2.5 billion so far. Based on reports that these new
facilities were not being designed and constructed to be
world class, the Congress mandated that an independent
review be conducted of their design plans." The NCR
BRAC Health Systems Advisory Subcommittee (HSAS)
of the Defense Health Board, augmented with health care
facility architects and other subject matter experts, was
charged with completing this independent review. 5 The
Defense Health Board is the official external advisory
body for health-related matters for the Department of
Defense, and the NCR BRAC HSAS had been previously
established to advise the Department of Defense
about the creation of a joint armed forces integrated delivery
system to serve active duty and retired military personnel
and their dependents in the NCR.
Because no recognized entity had defined world-class
medical facility, the NCR BRAC HSAS needed to
develop an operational definition that could be used to
objectively assess the plans for the new military medical
centers. In developing its definition, the NCR BRAC
HSAS interpreted medical facility to mean the totality of
the physical environment; the processes and practices of
providing care; the diagnostic, treatment, and other technologies
used; the adequacy, expertise, and morale of the
staff; and the organizational culture.' Because the Congressionally
mandated review focused primarily on the
design and construction of the facilities' physical environment,
the committee's definition required criteria that
IMedsphere Systems Corporation, Carlsbad, CA
Corresponding Author:
Kenneth W. Kizer, MD, MPH, 3740 Clover Valley Road, Rocklin, CA 95677
Email: kenneth.kizer@medsphere.com specifically addressed facility architecture and design
characteristics linked to health care outcomes. The committee
first looked to existing multidimensional approaches
to defining performance excellence (eg, the Malcolm
Baldrige Award for Quality) but found none that sufficiently
addressed facility structural architecture as well
as care processes, staffing, leadership, and other performance
factors. The committee also took the position that
the term world class should be reserved for performance
that is truly exceptional based on meeting measurable
performance specifications.
Much has been learned over the past 3 decades about
the importance ofthe physical environment of health care.
Structural design significantly affects the efficiency ofmaking
correct and timely diagnoses and the ease of administering
treatment; the occurrence of hospital-acquired
infections, medical errors, worksite injuries, and resource
wastage; and the creation ofa healing milieu.v" Combined
with the organization's social support systems and culture,
a facility'S physical environment also significantly influences
the attitude and morale of patients, famil ies, and
health care workers; staff satisfaction and turnover; and the
overall effectiveness of the health care team.9,lO
The committee concluded that the Walter Reed National
Military Medical Center was not being designed to be a
world-class medical facility, despite the diligent efforts of
many individuals and substantial expenditure of public
funds, and offered multiple suggestions for how the goal
might be achieved.' Design of the Fort Belvoir Community
Hospital was found to be much closer to achieving
the Congressional intent. 5
Achieving World-Class Health Care?
Achieving world-class performance is a commonly stated
goal, but one that is uncommonly reached. Achieving
world-class performance is very hard, requiring a clear
vision, unwavering commitment, perseverance, and consistent
performance at the upper limit of what has been
demonstrated to be possible.
Achieving world-class excellence in health care
requires doing many things exceptionally well, including
applying evidence-based facility design principles; utilizing
state-of-the-art processes and the latest advances
in the biomedical, informatics, and engineering sciences;
using the most appropriate technologies in an easily accessible
and safe healing environment; employing the right
number of well-trained, competent, and compassionate
caregivers who are attuned to patients' and their families'
culture, life experience, and individual needs; providing
care in the most condition-appropriate setting; and having
pragmatic but visionary leadership.
Many of the architectural design characteristics, care
practices, and other organizational processes required for
a medical facility to achieve a level of health care performance
excellence that would qualify as being world class
in other settings can be objectively described and specified.
The NCR BRAC HSAS organized these specifications
into 18 categories within 6 domains.' These
specifications provide a detailed yardstick for assessing a
health care organization's claim of providing world-class
health care, as well as a strategic framework for those
aspiring to achieve this level of excellence. These specifications
were recently codified into federal law. 11 Of note,
these specifications may require modification when
appropriate to an organization's mission. For example, a
world-class cancer or pediatric center may provide services
in fewer specialties and subspecialties and not use
all the same technologies as a world-class general acute
care hospital, or a world-class community hospital may
be engaged in relatively fewer scholarly activities than a
world-class academic medical center.
Importantly, however, achieving a level of performance
that would qualify health care to be world class
requires more than just implementing the specifications
detailed by the NCR BRAC HSAS.5 These things are
necessary, but they are not sufficient. A substantial part
of achieving health care excellence that would qualify
as being world class derives from a facility's "invisible
architecture"-that is, its values, culture, and emotional
climate. This invisible architecture constitutes the soul
of the organization and is what catalyzes the synergies
between and among the physicians, nurses, and other
staff and the facility's physical environment and technology
that drives it to achieve world-class excellence. The
elements of this invisible architecture are not well measured
with currently available methods, but their manifestations
can be described in qualitative terms.
World-class health care is achieved by going above
and beyond compliance with professional, accreditation,
and certification standards to bring the best ofthe art and
science of medicine together in a focused effort to meet
the physical, mental, social, and spiritual needs of the
patient. World-class health care is achieved when highly
skilled professionals work together as practiced teams
with precision, passion, and a palpable commitment to
excellence within an environment of inquiry and discovery
that creates an ambience that inspires trust and communicates
confidence. World-class health care is achieved
by routinely performing at the theoretical limit of what
is possible and consistently and predictably delivering
high-quality care and optimal treatment outcomes at a
reasonable cost to the patient and society. World-class
health care routinely envisions what could be an
What Is a World-Class Medical Facility?
Kenneth W. Kizer, MD, MPH1
The term world class is often used in service and retail
industries, athletic competition, and other non-health care
settings to describe exceptionally good service or outstanding
performance. Being characterized as world class is a
high distinction accorded to an elite few and is generally
taken to mean that one has achieved a level of performance
excellence that ranks among the very best ill the world.
The term world class has been increasingly used in
health care in recent years, although in most such instances
this has been a self-designation made on the basis of
unspecified criteria. For example, a recent Internet search
of the terms world-class health care and world-class
medical center found more than 100 health care organizations
marketing their services as world class, but very few
offering any specifications to support the claim. Similarly,
in opposing national health care reform legislation, 3 former
presidents of the American Medical Association stated
that "Most Americans live within an hour's drive of a
world-class medical facility,"} but provided no explanation
of what is a world-class medical facility. Likewise, in
describing the Joint Pathology Center that will replace
the famed Armed Forces Institute of Pathology, the
Department of Defense states that it will be a worldclass
institution.f-' but provides no functional explanation
of what this means.
Defining World-Class Medical Facility
Care for military personnel located in and around the
nation's capital has long been provided by the Walter
Reed Army Medical Center and the National Naval Medical
Center. In 2005, the Base Realignment and Closure
Commission (BRAC) mandated consolidation of these
2 institutions into a new Walter Reed National Military
Medical Center that would be constructed on the grounds
of the National Naval Medical Center in Bethesda,
Maryland.' This new medical facility is intended to provide
a continuum of primary to tertiary care for active duty
and retired military personnel and their families living in
the National Capital Region (NCR}-the geographic area
that includes Washington, DC, adjoining areas of Virginia
and Maryland, and portions of West Virginia, New Jersey,
and Pennsylvania-as well as comprehensive care for
wounded military personnel returning from combat
overseas.
In authorizing funding for the new Walter Reed
National Military Medical Center and a new military
community hospital at Fort Belvoir in Virginia, the Congress
directed that they be designed and constructed to be
world-class medical facilities+ although no operational
specifications were provided that would ensure accountability
for the use of the appropriated public fundssome
$2.5 billion so far. Based on reports that these new
facilities were not being designed and constructed to be
world class, the Congress mandated that an independent
review be conducted of their design plans." The NCR
BRAC Health Systems Advisory Subcommittee (HSAS)
of the Defense Health Board, augmented with health care
facility architects and other subject matter experts, was
charged with completing this independent review. 5 The
Defense Health Board is the official external advisory
body for health-related matters for the Department of
Defense, and the NCR BRAC HSAS had been previously
established to advise the Department of Defense
about the creation of a joint armed forces integrated delivery
system to serve active duty and retired military personnel
and their dependents in the NCR.
Because no recognized entity had defined world-class
medical facility, the NCR BRAC HSAS needed to
develop an operational definition that could be used to
objectively assess the plans for the new military medical
centers. In developing its definition, the NCR BRAC
HSAS interpreted medical facility to mean the totality of
the physical environment; the processes and practices of
providing care; the diagnostic, treatment, and other technologies
used; the adequacy, expertise, and morale of the
staff; and the organizational culture.' Because the Congressionally
mandated review focused primarily on the
design and construction of the facilities' physical environment,
the committee's definition required criteria that
IMedsphere Systems Corporation, Carlsbad, CA
Corresponding Author:
Kenneth W. Kizer, MD, MPH, 3740 Clover Valley Road, Rocklin, CA 95677
Email: kenneth.kizer@medsphere.com specifically addressed facility architecture and design
characteristics linked to health care outcomes. The committee
first looked to existing multidimensional approaches
to defining performance excellence (eg, the Malcolm
Baldrige Award for Quality) but found none that sufficiently
addressed facility structural architecture as well
as care processes, staffing, leadership, and other performance
factors. The committee also took the position that
the term world class should be reserved for performance
that is truly exceptional based on meeting measurable
performance specifications.
Much has been learned over the past 3 decades about
the importance ofthe physical environment of health care.
Structural design significantly affects the efficiency ofmaking
correct and timely diagnoses and the ease of administering
treatment; the occurrence of hospital-acquired
infections, medical errors, worksite injuries, and resource
wastage; and the creation ofa healing milieu.v" Combined
with the organization's social support systems and culture,
a facility'S physical environment also significantly influences
the attitude and morale of patients, famil ies, and
health care workers; staff satisfaction and turnover; and the
overall effectiveness of the health care team.9,lO
The committee concluded that the Walter Reed National
Military Medical Center was not being designed to be a
world-class medical facility, despite the diligent efforts of
many individuals and substantial expenditure of public
funds, and offered multiple suggestions for how the goal
might be achieved.' Design of the Fort Belvoir Community
Hospital was found to be much closer to achieving
the Congressional intent. 5
Achieving World-Class Health Care?
Achieving world-class performance is a commonly stated
goal, but one that is uncommonly reached. Achieving
world-class performance is very hard, requiring a clear
vision, unwavering commitment, perseverance, and consistent
performance at the upper limit of what has been
demonstrated to be possible.
Achieving world-class excellence in health care
requires doing many things exceptionally well, including
applying evidence-based facility design principles; utilizing
state-of-the-art processes and the latest advances
in the biomedical, informatics, and engineering sciences;
using the most appropriate technologies in an easily accessible
and safe healing environment; employing the right
number of well-trained, competent, and compassionate
caregivers who are attuned to patients' and their families'
culture, life experience, and individual needs; providing
care in the most condition-appropriate setting; and having
pragmatic but visionary leadership.
Many of the architectural design characteristics, care
practices, and other organizational processes required for
a medical facility to achieve a level of health care performance
excellence that would qualify as being world class
in other settings can be objectively described and specified.
The NCR BRAC HSAS organized these specifications
into 18 categories within 6 domains.' These
specifications provide a detailed yardstick for assessing a
health care organization's claim of providing world-class
health care, as well as a strategic framework for those
aspiring to achieve this level of excellence. These specifications
were recently codified into federal law. 11 Of note,
these specifications may require modification when
appropriate to an organization's mission. For example, a
world-class cancer or pediatric center may provide services
in fewer specialties and subspecialties and not use
all the same technologies as a world-class general acute
care hospital, or a world-class community hospital may
be engaged in relatively fewer scholarly activities than a
world-class academic medical center.
Importantly, however, achieving a level of performance
that would qualify health care to be world class
requires more than just implementing the specifications
detailed by the NCR BRAC HSAS.5 These things are
necessary, but they are not sufficient. A substantial part
of achieving health care excellence that would qualify
as being world class derives from a facility's "invisible
architecture"-that is, its values, culture, and emotional
climate. This invisible architecture constitutes the soul
of the organization and is what catalyzes the synergies
between and among the physicians, nurses, and other
staff and the facility's physical environment and technology
that drives it to achieve world-class excellence. The
elements of this invisible architecture are not well measured
with currently available methods, but their manifestations
can be described in qualitative terms.
World-class health care is achieved by going above
and beyond compliance with professional, accreditation,
and certification standards to bring the best ofthe art and
science of medicine together in a focused effort to meet
the physical, mental, social, and spiritual needs of the
patient. World-class health care is achieved when highly
skilled professionals work together as practiced teams
with precision, passion, and a palpable commitment to
excellence within an environment of inquiry and discovery
that creates an ambience that inspires trust and communicates
confidence. World-class health care is achieved
by routinely performing at the theoretical limit of what
is possible and consistently and predictably delivering
high-quality care and optimal treatment outcomes at a
reasonable cost to the patient and society. World-class
health care routinely envisions what could be an
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