Connected Thinking Blog - NACHRI Conferences

Closing Plenary: Assessing and Improving Patient Safety and Infection Prevention and Control in Your Building Project

NACHRI Facilities Design 2009 closes with a presentation from Judene Bartley, vice president of Epidemiology Consulting Services, Inc., and John Reiling, Ph.D., president and CEO of Safe by Design.

Bartley starts with the presumption that it is possible to reduce hospital acquired infection rates, but it is very hard to quantify what changes affect what outcome improvements. Precise controlling of variables is difficult in the ever-changing health care environment. Particularly in pediatrics, creating a static environment is impossible.

Facllities design and contruction is a major contributor to reducing hospital acquired infections. A well-designed environment helps eliminate medication errors, transmittion of drug-resistant organisms and other infections. 

An HVAC system that provides clean air and proper flow can expedite healing and reduce infections. In addition, air direction and speed and a well-sealed environment all affect the healing process. Using the right surfaces also has a huge impact on creating a clean environment.

Hospital realities

Reiling shares about his father dying last year from a hospital acquired infection that was supposed to help address his chronic leukemia. The statistics are staggering: every 22 admits in adult hospitals, someone gets a hospital acquired infection. One in every 300 dies. In medical/surgical hospitals, one out of every 10 medicines given is wrong.

Reiling's rule, speaking from experience as a former hospital CEO: "Never go to a hospital by yourself -- always take someone else with you. It is much, much safer."

So why all the errors?

We have culture, processes and systems that set people up for failure, and we have facilities that lock in erroneous processes. A competent person in a broken culture and facility will still make mistakes and cause harm.

2002 was the first year that facilities were considered as a potential factor in causing harm.

Reiling recommends Jim Reason's book Managing the Risk of Organizational Accidents as an excellent resource for reducing harm in the health care setting.

Design around common errors
When you identify problems and commor errors, think about how your facilities design could address those errors. Don't just design around successes, but design around failures to elminate the odds of details going wrong or being missed by folks who are lazy or in a hurry.

The human factor has to figure into every equation. People will do what is right in front of them, what is most immediate, what is shortest. Think about a place where a sidewalk is counterintuituve, so a dirt path has been worn connecting the shortest distance across a courtyard. Hospital design shares similar principles -- design around intuitive, shortest distance paths and compliance with common sense safety improvements will increase.

Improving outcomes and reducing infection rates are not linked to any one change -- they are linked to a bundle of common-sense improvements that create a culture of safety. It isn't just about evidence based design, but it is about implementing ideas that will lessen the risk of harm.

What have you learned at this conference that you will take back and work to implement at your own hospital?

Plenary Presentation: Evidenced-based Design Today

Roger S. Ulrich, Ph.D., offers his thoughts on where we are today with evidence-based design in health care, particularly as it applies to children's hospitals. Ulrich is a professor of architecture and a fellow of the Center for Health Systems & Design at Texas A&M University and is known as the guru of evidence-based design.

Evidence-based design (EBD) research has grown substantially over the years, in particular, infection research has grown rapidly. However, most studies focus on adult patients in acute care hospitals and there has been relatively little research done for pediatrics or for how staffing affects care.

There have only been 60-80 randomized controlled trials to quantify the effects of EBD. In most cases, design changes are done in bundles, so it is show concrete evidence that a certain variable causes a certain outcome.

EBD is gaining momentum, with endorsement from leading quality organizations, including NACHRI, Joint Commission, U.S. Agency for Healthcare Research and Quality, and various credit rating agencies. Even in the current economic climate, the credit agencies have formally endorsed EBD because strong EBD in a hospital helps ensure long-term financial strength.

Karolinska University Hospital, Stockholm -- which Ulrich sees as arguably the most important health care project in the world right now --  is the third- or fourth-ranked research center in the world. The Karolinska Research Center has been a leader in EBD. The new building being built as a clinical home for the hospital is centered on EBD.

Examples of EBD

Ulrich demonstrates numerous examples of ways in which EBD is changing every level of health care -- from the big design to the minute details. For example, in patient rooms, sinks with the drains in line with the faucets (as is traditional) can be the source of MRSA. Disease can live in the drain and become airborne when agitated by a person washing hands when the high-pressure water hits the drain and disperses the particles into a two meter airborne cloud of infection. A change as simple as having sinks with offset drains/faucets can reduce hospital infection.

At the macro-level of design, the single most important EBD recommendation for improving patient safety is providing single-bed rooms for patients. A wealth of evidence shows that single bed rooms are far better for patient health and reduces complications and lengths of stay.

The importance of nature

Reducing stress can be achieved by exposing patients and staff to nature, particularly to well-designed gardens. On all scales, stress, pain, anxiety, sadness and other negeative feelings are reduced by being in a garden, vs. even a well-designed, comfortable interior lounge area. Legacy Emanuel Hospital in Portland, OR, has a world famous children's garden that sets the standard for well-designed gardens. Nature distraction can provide substantial and clinically important alleviation of pain. Several well-controlled studies show this affect. Bronson Methodist Hospital in Kalamazoo, MI, is a leading hospital for design using nature distraction, with the whole hospital based around a garden.

Light reduces depression

In controlled tests, a variable as seemingly simple as have a window with sunlight vs. a window that is perpetually in shadow of another building has dramatic affects on outcomes. Patients in shadow use more than 25 percent more pain medication than peer patients in sunlit rooms.

Well-designed floorplans

Well-designed floors will have staff walking 2-5 km per day; vs. traditional designs will usually have 10-18 km per day of staff travel time. This approximately doubles the amont of quality time that staff can spend with patients per day. Decentralized supplies and workstations for staff decrease wasted time and improve patient care.

Staff share in EBD benefits

Nurses have lower stress and greater alertness when they are exposed to lots of natural light and to views of nature. Other elements of EBD also help increase staff satisfaction, reduce staff turnover, increase productivity and reduce costs.

For more information on evidence-based design in pediatrics, check out the groundbreaking NACHRI report, Evidence for Innovation: Transforming Children's Health Through the Physical Environment.

What examples of evidence-based design are being used in your facility, and how have you seen those changes affecting patient care and staff satisfaction?

Ambient Design for a New ED Experience

Tim Burrill, assistant administrator of Walt Disney Pavilion at Florida Hospital for Children in Orlando, FL, shared his experience with the creation of a new emergency department. The ED, about the size of a football field, is among the largest pediatric EDs in the country.

The emergency department as it exists today is the product of an ongoing partnership that began about three years ago, when the Walt Disney Co. came to the children's hospital with an interest in partnering to help care for children. Careful discussions resulted in a partnership that is designed to strengthen both entities. 

The whole ED was originally designed without Disney involved. The pediatric ED was designed around Lean design principles, but looked just like the adult ED. The advent of the Disney partnership opened up opportunities to discuss new ideas for look and feel. Philips Electronics also stepped to the table and offered their Ambient Experience technology to help create a rich patient experience that is people-focused health care. Burrill stresses that ambient environments "are not just colored lights, but are about caring for people and creating an experience." The interactive ambient experience is an experiment that is under way and ongoing, so quantitative results are not yet available for the effectiveness of the ambient design.

The ambient environment

The ED entrance has its own music and softly shifting colored lights that help set the stage for patients as they arrive. The lounge area is meant as a very temporary waiting room for patients but is filled with wall-sized interactive screens that engage children while they wait. Burrill shares that these screens -- while cool and techy -- were an experiment that wouldn't be repeated. Not because they aren't fun and effective, but because they don't provide high enough ROI for their cost, since patients spend so little time in the lounge.

Exam rooms have fully interactive diplays and ceiling cove lighting that help create a full-immersion experience for patients. The ceiling cove and the interactive wall display are linked to create a cohesive environment. The interactive displays are projected from the ceiling onto the walls. Various themes are united through the wall display, lighting, and soundtracks that help bring all the pieces together. Children can change themes whenever they would like, and when they change one element, the entire enviironment changes.

"The coolest part about the whole thing is the unexpected results you get from this," Burrill shares. "We didn't fully understand the impact this would have on parents and families.It turns out this impacts familes almost as much -- or more -- than the children. And when parents walk into the enviironment and are calm, their calm in turn affects their children."

Rooms don't have curtains because they have electrified glass -- when a current is applied, the glass becomes opaque. This allows for privacy for families, but makes it really easy for staff to check on patients.

The hospital started recieving Press Ganey scores in January, based on the new facility. There is no benchmark for the old environment, but the new ED can benchmark against inpatient rooms, which are scoring incredibly low. The new ED rooms created a patient experience that provided very high Press Ganey scores without any staff training or other improvements. The radical change was soley caused by the environment. Upcoming staff training should continue to improve scores.

Lessons learned

• "Technology" works only for a short period of time as a distraction
• Start as soon as possible in design -- retrofitting is far more expensive than designing for new technology in the first place
• Balance the color palette for the hospital -- color is important, and technology should not be the only thing providing color
• Provide adequate lighting for examinations
• Other uses for the wall display -- do not use television on the wall displays, but do use the wall displays for patient status information when needed for the whole care team to see
• Lounge design needs improvement
• Work on customer experience

Future design

Disney is not in the business of taking care of ill or injured children. Disney is in the role of entertaining and educating children. For this reason, Disney characters do not appear in patient care areas. The hospital that is being built will have a fully Disney themed lobby, bringing together characters from four movies: The Lion King, The Little Mermaid, Jungle Book and Brother Bear. All the movies center around the natural world, and are being brought together to create as welcoming an envrionment as possible for patients entering the hospital.

Sign up for the 2009 NACHRI Annual Meeting being held in Orlando on October 11-14, where you will have a chance to tour the new Florida Hospital for Children.

Managing Clinical Process Change During Design, Renovation and Occupancy

The Hospital for Sick Children in Toronto, ON, experiencing rising patient acuity, worked with Stantec Architecture to transform a tight, outdated emergency department with a complete reassessment of process, IT, and space utilization.

Presenters spoke about three primary process changes:

1. Decant lower acuity patients to clinics rather than admitting to the emergency department
2. Two tier patient triage, with some patients straight to bed 
3. Restructured care teams to balance patient acuity treatment across teams.

System changes during redesign

• Implemented electronic patient tracking system
• Restructured the supply chain
• Aided personal service personel workflow to make it more efficient

Physical changes during redesign

• Program need exceeded space by approximately 40 percent
• Room sizes were made consistent at 120 square feet each, with the same floorplans throughout
• Triage, registration and waiting were moved to the entrance of the facility to streamline patient flow

Patient and staff circulation were changed to reduce crowding in hallways and improve workflow.

During the renovation, the emergency department had to remain open, which created a lot of logistical difficulties, and the necessity for collaboration between the hospital and the architects. For more details on operations during the rennovation, see the presenters' PowerPoint slides.

Lessons learned

• The team learned the importance of starting to change process before the physical space is renovated. 
• Team communication and continuity was shown to be important for success.
• Starting early and challenging all design choices, products or hospital procedures were things that the team would repeat on future similar projects.
• For the future, the team would more carefully study the impact of phasing with respect to temporary requirement, and some of the gaps that this may cause.
• In addition, a way to modify design during construction should be developed as some of the impacts of operational changes were discovered later in the construction phases of the project.  

What areas of your hospital are being redesigned and what are the challenges you are facing or the best solutions you are developing to meet those challenges?

Welcome to NACHRI Facilities Design Conference 2009

Follow the NACHRI Facilities Design Conference 2009 for the next few days to learn about the latest strategies and ideologies for creating facilities to address increasing capacity, changes in population, family centered care, hospital IT infrastructure, energy demands, staff needs and, more than ever, an unpredictable future.

Dell Children's Medical Center of Central Texas is the local host hospital for the conference. Recently awarded LEED Platinum status, Dell Children's helps showcase some of the possibilities for health care facility design for the future.

If you've got general thoughts about the conference, or recommendations for favorite restaurants or attractions in Austin, feel free to share those here.