architecture and design track- designing for enhanced ... · design rack: ing t satisfaction heila...

Architecture and D

esign Track:D

esigning for Enhanced Patient Satisfaction

Sheila F. Cahnm

an, AIA, ACH

A, LEED AP, Founding

Principal, JumpG

ardenC

onsulting LLC

Tamm

y Thompson, N

CAR

B, EDAC

, CLC

, President, Institute for Patient-C

entered Design, Inc.

Designing for Enhanced Patient Satisfaction

Sheila F. Cahnm

an, AIA, ACH

A, LEED AP

Founding Principal

JumpG

ardenC

onsulting LLC

Learning Objectives

1.Define the five proven elem

ents for enhancing patient satisfaction

2.O

utline current research on how the physical environm

ent affects the patient experience

3.Describe physical im

provements that m

ost cost effectively raise HCAHP scores Review

physical improvem

ents that most

cost effectively raise HCAHP scores.

Definition of Patient Experience

The Beryl Institute

2017 Value Based Purchasing Domains

2015 Performance Period

Patient Experience of

Care, 25%

Clinical Care, 30%

Efficiency, 25%

Safety, 20%

Medicare Spending

per Beneficiary

Selected Indicators(PSI /HAI)

HCAHPS SurveyPerform

ance Dimensions

Clinical Process &O

utcomes

(Flu Imm

unization &

Morality Rates)

Hospital

Consum

er

Assessm

ent of

Healthcare

Providers and

Systems

2017 HCAHPS Composites (25%

weight)

Category (Composite)

Summ

ary of Questions

1Com

munication –

Nurse

Courtesyand respect

Listening skillsClear explanation

2Com

munication –

Doctor Courtesy

and respectListening skillsClear explanation

3Responsiveness of Staff

Help getting to bathroomAssistance

in bathroomResponse to patient call

4Pain M

anagement

Timely m

edication Pain controlStaff assistance

5Com

munication

of Medications

ClearexplanationSide effects described

6Discharge Inform

ationClear discharge explanationW

ritten information

7Environm

ent –Cleanliness and Q

uietnessNoise level at nightCleanliness of room

and bathroom

8O

verall RatingO

verall experience

CAHPS

The Clinician and Group CAHPS (CGCAHPS) survey: Standardized tool to m

easure patient perceptions of careprovided by physicians in an office setting.

HCAHPS• Com

munication

• Quiet at N

ight• Inform

ation About Medications

• Discharge Information

• Cleanliness• Responsiveness

• Pain Managem

ent

• Ongoing Em

otional Support• Fam

ily Involvement &

Care Team Integration

• Avoidable Disruptions Minim

ized• Com

passionate, Empathetic Caregivers

• Clear, Actionable Patient Education• Up-to-Date and Thorough Inform

ation• Physical and Em

otional Needs Anticipated

Broadening Our Am

bition

Advisory Board

How can the built environm

ent enhance the Patient Experience?

Do patients in appealing rooms m

ore favorably evaluate healthcare providers and services than do patients in typical room

s?Health Care M

anagement Review

2003

Mercy W

estCincinnati, O

hio

HCAHPS SCORES

National Average

Patients who reported Y

ES

, they would definitely recom

mend the hospital.

70%

ST JOSEPH'S HO

SPITALSaint Paul, M

NSAINT JO

SEPH REGIO

NAL MEDICAL CENTER

Mishaw

aka, INCO

LUMBIA ST M

ARYS HOSPITAL

Milw

aukee, WI

OUR LADY O

F LOURDES REG

IONAL M

EDICAL CENTER

Lafayette, LAPRO

GRESS W

EST HEALTHCARE CENTERO

Fallon, MO

(HCA) METHO

DIST STONE O

AK HOSPITAL

San Antonio, TX75%

74%

81%

73%

77%

83%

HCAHPS SCORES

National Average

Patients who reported Y

ES

, they would definitely recom

mend the hospital.

70%

ST JOSEPH'S HO

SPITALSaint Paul, M

NSAINT JO

SEPH REGIO

NAL MEDICAL CENTER

Mishaw

aka, INCO

LUMBIA ST M

ARYS HOSPITAL

Milw

aukee, WI

OUR LADY O

F LOURDES REG

IONAL M

EDICAL CENTER

Lafayette, LAPRO

GRESS W

EST HEALTHCARE CENTERO

Fallon, MO

(HCA) METHO

DIST STONE O

AK HOSPITAL

San Antonio, TX75%

74%

81%

73%

77%

83%

New

facilities = high scores

Key elements for im

proving the patient experienceThe Beryl Institute 2013

“How am

I supposed to sleep with all this

racket?”

Reducing noise

Private rooms reduce exposure to

noise levels that can cause stress and negative health effectsU

lrich et al., 2008.

Reduced noise levels im

proved sleep and m

ood, better pain tolerance Janssen et al., 2000

Glass at nurse station helps reduce noise Kaiser Perm

anente, Gaithersburg, MD

Improving the

short stay environment

Good Samaritan W

estKearney, N

E

“ I had to wait so long to

be discharged and then the instructions they gave us w

ere confusing.”

How can facility design support the discharge process and

improve com

munication

with patients and fam

ilies?

1 in 5 Medicare patients is readm

itted w

ithin 30 days of discharge

3% reduction in reim

bursements

if above the acceptable CMS threshold in 2015 &

beyond

Kaiser Health N

ews August 2012

Designated quiet, meeting areas for m

edical staff, patients and families

Park Nicollet, M

elrose Institute, St. Louis Park, MN

Family N

ichesGalterPavilion, N

orthwestern M

emorial Hospital, Chicago, IL

Surgery Status Board

Family com

munication

Family com

munication

Kaiser Permanente W

estside Medical C

enterH

illsboro, Oregon

“I’m stretched thin –

I wish I could give each of m

y patients the attention they deserve.”

How can facility design best support responsiveness of staff

and effective rounding?

Decentralized work areas increase staff responsiveness

Sanford Health, Heart Hospital, Sioux Falls, SD

Decentralized Patient SuppliesSoin

Medical Center, Beavercreek, O

hio

Kaiser Permanente W

estsideH

illsboro, Oregon

Scripps Hospital

San Diego, C

A

Activating Fitness

Respite for Staff

Mary Bridge C

hildren’s Hospital, Tacom

a, WA

“A hospital is the last place I want

to be when I’m

sick and in pain –I feel really stressed!”

How can facility design best

reduce stressand support pain managem

ent?

Pain in its Environmental Context: Im

plications for Designing Environm

ents to Enhance Pain Control, Pain, February 2008M

alenbaum, Keefe, W

illiams, Ulrich, and Som

ers

Natural light

Views of nature

Virtual reality

Access to nature reduce stress M

ercy Medical Center, Baltim

ore, MD

Natural and sim

ulated views of nature

University of Kentucky, Albert B. Chandler Hospital -Pavilion A, Lexington, KY

Natural scenes reduce stress

Stone Psychiatric Unit, Northw

estern Mem

orial Hospital, Chicago, Illinois

Virtual reality

Wayfinding

Kaiser Permanente W

estside Medical C

enterH

illsboro, Oregon

Northw

estern Mem

orial Hospital

Chicago, Illinois

Concierge desks and self-service kiosks

Concierge desks and self-service kiosksRegions Hospital, Expansion, St. Paul, M

N

Patient privacy“W

hile patient choice and controlare prim

ary drivers of patient satisfaction, patient privacy is also a predictor.”

Factors predicting patients’ perception ofprivacy and satisfaction for em

ergency care. Em

ergency Medicine Journal (28). Lin, Y. K., &

Lin, C. J. (2010)

“The perception of hospital quality em

bodies amenities

as well as clinical quality“

Patient amenities

Dining AreaStafford Hospital Center, Stafford, VA

“My m

om doesn’t

mind w

aiting for the doctor, but I’m

used to getting inform

ation w

hen and how I need

it.”How do w

e incorporate differing expectations of various generations?

Silent GenerationBaby Boom

ersGeneration X

Millennials

Born before 19421943-1960

1961-19811982-

Physician DirectsEngage M

eEducate

Me

Connect with M

e

Hospital Reputation;Physician

ReferralResearch options;Physician

InfluencedHealthcare

consumer

Social Netw

orksCustom

er Experience

BrandingSelf Directed SearchesCustom

er ExperienceW

ellness & Prevention

Thompson Reuters Research Brief: M

atching the Market:

Using Generational Insights to Attract and Retain Consum

ers

What innovative

tools, techniques or processeshelp design for a better patient experience?

Engaging our clients in the process to understand their patients’ journey

Experience mapping

Mary Catherine Bunting Center at M

ercy

Park Nicollet Experience M

apping

Park Nicollet W

omen’s Center

Image and Experience M

apping Process

Image and Experience M

apping Process

Guiding Principles of Patient-Centered Design

Tamm

y Thompson, N

CAR

B, EDAC

, CLC

, P

resident

Institute for Patient-Centered D

esign

Learning Objectives Continued

4.Analyze m

ethods for addressing the needs of patients through the use of the 10 Guiding Principles of Patient-Centered Design.

5.Identify com

mon obstacles for patients and fam

ilies that are inadvertently created in the design process.

6.Describe m

ethods of gaining patient and family feedback

through design simulation.

“A thoughtful healthcare designer, no matter how

accomplished,

remains a student of the patient…

”

Design with Patients in M

ind…

Accordingto

“ToErris

Human,”

areportreleased

in1999

bythe

InstituteofM

edicine(IO

M),“at

least44,000

people,andperhaps

asm

anyas

98,000people,die[d]

inhospitals

eachyear

asa

resultofm

edicalerrorsthat

couldhave

beenprevented.”

Inaddition,estim

atedcost

resultingfrom

medicalerrorfellbetw

een“$17

billionand

$29billion

peryearinhospitalsnationw

ide.”*

*IOM

, http://ww

w.iom

.edu/~/media/Files/Report%

20Files/1999/To-Err-is Hum

an/To%20Err%

20is%20Hum

an%201999%

20%20report%

20brief.pdf

Problems associated w

ith “semi”-private patient room

s:•Lack

ofprivacy•M

edicalerror•Spread

ofinfection•Restricted

visitation•N

oise/aggravation•Safety/security

concerns

The Problem

Patient-Centered Care

8 Picker Principles of Patient-Centered Care**•

Respect for patients’ values, preferences and expressed needs•

Coordination and integration of care•

Information, com

munication and education

•Physical com

fort•

Emotional support and alleviation of fear and anxiety

•Involvem

ent of family and friends

•Transition and continuity

•Access to care

*Planetree, http://ww

w.planetree.org/PCCAM

.html

**Picker Institute, http://pickerinstitute.org/about/picker-principles/

Accordingto

Planetree*,in“a

patient-centeredapproach

tohealth

care,providerspartner

with

patientsand

theirfam

ilym

embers

toidentify

andsatisfy

thefull

rangeof

patientneeds

andpreferences.”

Patient-Centered Design"Patient-Centered

Design"is

aphilosophy

byw

hichhealthcare

facilitiesand

theirdesign

teams

compassionately

createand

developspaces

tobe

usedby

patients.The

10principles

ofpatient-centered

designaccount

forthe

needsof

patientsand

theirfam

ilies,andsupportm

ethodsfordeliveringthe

bestcareto

them.

Principles of Patient-Centered DesignPatient-centered design supports the practice of patient-centered care bycreating environm

ental conditions that facilitate healing. The following principles

may be applied to health facility design to engage patients.

1.Respect privacy

2.Facilitate com

munication, collaboration and trust

3.Encourage patient and fam

ily participation4.

Empow

er patients5.

Promote safety and security

6.Provide accessible accom

modations

7.Create a com

fortable environment

8.Facilitate healing

9.Support staff’s goals through design

10.Look for design opportunities to respond to unm

et needs

Patient Room Analysis

Caregiver’sZone

Handw

ashing sink

Hand sanitizer

Personal protective equipm

ent (PPE) organizer

Work surface

Computer/charting area

Headwall

Medical equipm

ent

Medical supplies

Patient’s Zone

Bed

Over-bed table

Bedside table/cabinet

Telephone

TV/entertainment system

Closet/Armoire

Patient bathroom

Handw

ashing sink


Family’s Zone

Sofa/sleeper

Desk

Guest chair

Storage


Nursing Rounds

Patients may be aw

akened during the day and night for care managem

ent. A standard routine is described below.*

•Take vitals signs -Average every 4 hours/more frequent per doctor’s orders

•Check urine output -usually done w

ith vital signs•C

heck or change the pain pump per hospital protocols -U

sually performed w

ith two

nurses at shift change and every 4 hours, unless special circumstances dictate

otherwise.

•Change IV fluids as needed

•Perform shift assessm

ents•Adm

inister medications per orders

•Draw

lab work per orders

•Check/change surgical dressings as required

•Check ventilator for som

e patients

*Interview w

ith LaShawna H

eflin, RN

1. Design that respects privacyDesign techniques that prom

ote privacy•U

se of single occupant patient rooms

•Planning techniques that minim

ize views of the

patient bed from the corridor

•Acoustic design to protect private conversations

•Designating patient transport elevators and corridors that shield patients from

public view

•Strategic placement of m

edical information to

conceal from public view

1. Design that respects privacy

Patient’s Voice

The pre-op room had actual w

alls but the end of the room w

as a large curtain. It was a

teaching hospital but the rooms w

ere too small to accom

modate m

ultiple providers so they flung open the curtain instead. I could see num

erous other patients directly across from

me w

ho were recovering on the other side of the hall. It w

as embarrassing to be

half naked and repeatedly examined w

hile people were w

alking by me and w

ondering w

hat the other patients could see…

-Cassie R

1. Design that respects privacy

2012 Patient Empow

ered Room W

inning Design by KahlerSlater

Provide adequate space for:•Patient com

munication w

ith caregivers•Expressed concern•Q

uestions•Patient/fam

ily education/training•Condition-specific education•Treatm

ent plan•Treatm

ent schedule•Hom

e training•Staff com

munication

•Training/mentoring

•Shift-change transfer of information

2. Design that Facilitates Comm

unication, Collaboration and Trust



Patient’s Voice:

During recovery, they were m

ore focused on the computer than on sim

ply sitting next to m

e but all of the monitors w

ere behind my head so I couldn’t see w

hat was causing

the alarms and it m

ade me feel vulnerable and discredited w

hen I wanted to see them

and w

as told not to worry.

-Anonymous

Patient’s Voice:

My relationship w

ith my oncologist totally changed w

hen his office moved to electronic

medical records. In the past, w

e sat down together and talked about m

y plan of care. I received personal attention. N

ow, I talk to his back.

-Anonymous



Patient-centeredcare

recognizesthat

thefam

ilyis

anim

portantpart

ofthe

careteam

.Fam

ily/friendsare

encouragedto

accompany

patientsduring

medicalvisits

andinpatienttreatm

ent.

Patient-centereddesign

accomm

odatesfam

ilyby

providingdesignated

spaceand

amenitiesforfam

ilym

embers.

Family presence m

ay:•Reduce the patient’s anxiety•Decrease the chance of m

edical error•Relieve staff by providing non-clinical patient assistance•Provide an added layer of security

Family Zone

3. Design that Encourages Patient and Family

Participation


Participation

Parent’s Voice:

There were so m

any times that I w

as there with no place to go. I rem

ember an

experience when m

y son coded and there was a vacant desk w

ith no chair so I sat underneath the desk, just praying that he w

ould survive. This has a long term

emotional im

pact; and I’m so glad that parents are now

invited to be a part of this, because the NICU becom

es our home too.

-Kelli Kelly, Founder & Executive Director, Hand to Hold hosted by the Institute for

Patient-and Family-Centered Care (IPFCC)


Participation

4. Design that Empow

ers Patients

Many patients feel vulnerable and helpless.

Design facilitates patient-centered care by allowing patients

to remain in control of their environm

ent.Designers should:•Provide access at the bedside to:

•Lighting control•Tem

perature control•Com

munication technology

•Provide direct access to the sink and toilet to promote

self-sufficiency.•Create opportunities to build trust w

ith:•Patient visibility of staff sinks•Designated areas for posting hospital standards•Sufficient collaboration space at the bedside

4. Design that Empow

ers Patients

5. Design that Promotes Patient Safety and

Security

Comm

on Patient Safety Concerns:•Infection prevention and control•Reduction of m

edical error•Reduction of patient accidents/falls•Security of units from

intruders•Protection of patients’ belongings

These concerns may be addressed by:

•Proper design of hand washing stations to prevent infection

•Standardization of procedure/treatment areas to prevent m

edical error•Provisions for unobstructed, clear, and w

ell-lit circulation paths to prevent falls•Secure unit layouts w

ith designated control points to prevent intrusion•Inclusion of locking cabinets and patient safes to protect belongings

5. Design that Promotes Patient Safety

and Security

6. Accessible DesignNot only m

ust a hospital provide access by law

to individuals with disabilities; but, it

must also consider the com

promised state

of its patients.

Many patients require assistance m

oving from

the bed to other areas of the room.

Accessible design methods:

•Provide sufficient maneuvering space for patients using m

edical or m

obility assistive equipment

•Install handrails along patient routes•Provide w

ide doors for staff to assist patients

6. Accessible Design

7. Design that Creates a Comfortable

Environment

Touch: “High-touch” materials, such as w

oodSm

ell:•Natural elem

ents with pleasant scents, such

as plants•Appropriate air exchanges to elim

inate odorsHearing:

•Natural elem

ents with soothing sounds, such

as fountains•Acoustic design to reduce noise

Sight:•Creative use of color, light and shadow

•Framing of interior and exterior view

s

Often

designersconsider

creativem

ethodsfordeveloping

comfortable

environments.

Thismay

beexplored

byseeking

methodsforengaging

thesenses.

7. Design that Creates a Com

fortable Environment

Parent’s Voice:

I wanted desperately just to rest m

y head against something and m

aybe recline a few

degrees. We spent about three and half hours in the ED that night. Perhaps 20 m

inutes of that w

as actual care interaction. The rest was w

aiting. I am not sure how

much of

the waiting m

ight be avoided through process improvem

ent, but any amount of

waiting w

ould have been more tolerable if I had been com

fortable. It wouldn't have

taken much to im

prove my com

fort and it would have im

proved my satisfaction

substantially.

Empathy is a crucial com

ponent of design. As designers we m

ust seek ways during the

development of the project to understand the needs of the visitors and w

hat resources w

ill truly improve their experience. They m

ay be less costly and fancy than we think.

Jonathan M. Bykow

ski, AIA

7. Design that Creates a Comfortable

Environment

8. Design that Facilitates HealingEnvironm

ental factors can affect the healing process. In addition to the therapeutic nature of pleasant spaces, other exam

ples include:•Lighting control: N

ICU babies respond favorably under controlled lighting•Sound: N

oise can cause aggravation and physiological indicators of stress (elevated blood pressure) in m

any patients•Tem

perature: Cooler temperatures discourage the

growth of pathogens

•Fresh air: Air exchanges promote infection control

Research is examining how

these factors impact

specific health conditions. The

same

factorsthat

impact

patientsm

ayaffect

hospitalstaffas

well.

Studiesindicatethatcliniciansm

akefew

ererrorswith

adequatelighting

andexperience

lessfatiguew

ithnaturallight.

8. Design that Facilitates Healing

Parent’s Voice: I w

ould have stayed with m

y baby longer; but, there was really no use

for me there w

hy she slept.

-Anonymous

Kangaroocare

canbe

promoted

frombirth.

Thereare

benefitsto

holdingthe

neonatew

hileshe

issleeping.Babies

areasleep

inutero,

but,sleepis

alsoan

activetim

eof

braingrow

th.Throughcontinuous

kangaroocare,they

learnm

other’svoice,scentand

movem

ent.Thereare

thingsthathappen

inthe

mother’s

arms

thatdonothappen

inan

incubator.

Dr.RobertWhite,N

eonatologist

8. Design that Facilitates Healing

9. Design that Supports Staff’s Goals

Operational goals m

ay be supported through design. •Throughput: Clear, sim

ple circulation allows shorter w

alking distances (reduced nurse fatigue), faster access to necessities and quicker patient transport.

•Universal patient room

s allow a reduction in transfers.

•Designing to prevent accidents and infection may ultim

ately result in a shorter length of stay and few

er unreimbursed expenses.

•Patient Education

•Coordination of care allows clinicians to com

municate, reducing

medical error.

•Decentralized teaming/collaboration spaces

•Electronic Medical Records (EM

R) Infrastructure•Pods of com

plementary outpatient clinics


Parent’s Voice:

Ifortunately

dida

tonof

researchbut

most

parentsw

erecom

pletelyoverw

helmed

andlost.Perhaps

asm

allreadinglibrary

with

literatureand

listsofreputable

websitesforpreem

iehealth

anddevelopm

ent.

-Anonymous

10. Design that Arises from an

Unmet Need

Innovation arises through thoughtful consideration of the end user. Learning the intim

ate details of a user’s experience sparks revelation.

LessonLearned:

Shadowa

caregivertoidentify

makeshiftsolutionsthatare

usedbecause

thecurrentdesign

orproductdoesnotm

eettheneed.

Project by: Graeme Fielder, Josh Felerand

MikkelSoerensen

Course: Redesigning the NICUInstructors: Jules Sherm

an and William

Rhine, MD

Stanford University Hasso

PlattnerInstitute of Design/d.school

10. Design that Arises from an

Unmet Need

Parent’sVoice:If ALL overnightnurses had to use RED flashlights or Green Night-vision goggles, nowthat w

ould be amazing for parents and patients trying to sleep.

Some nurses and staff

would com

e in, bang the doors, and turn on all the lights in the middle of the night, to

see what they w

ere doing, every 2-4 hours depending on the meds. O

vernight nurses should have to pass a test w

here they can go into a completely dark room

, monitor the

patient with green light, infuse m

edications, take vitals, and produce noise lower than a

set decibel amount.

(We called the great night nurses "Night Ninja's".)

-Rozanne Hug

10. Design that Arises from an Unm

et Need

What is YO

UR Solution?

We appreciate your interest in Patient-Centered Design

QU

ESTION

S?

Contact:Tam

my S. Thom

psonInstitute for Patient-Centered Design, Inc.300 N

Cedar Street, Suite C-1Sum

merville, SC 29483

tthompson@

patientcentereddesign.orgw

ww

.patientcentereddesign.org

Copyright © 2015 Institute for Patient-Centered Design, Inc.

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