understanding healthcare design: designing patient care spaces that work

8/14/2019 Understanding Healthcare Design: Designing Patient Care Spaces that Work

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Understanding Healthcare Design Designing Spaces that Work

Jesus Cepero, MSN, MPA, RN, NEA- BCVice President, Critical Care and Heart Institute

Childrens National Medical Center, Washington, D.C.

Rose Szeles, MS, RN, NE-BCManager Professional Nursing Practice

Childrens National Medical Center, Washington, D.C.

First, we shape our buildings;thereafter, they shape us.

Winston Churchill


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So the stakes are high, the overarching desire is toget it right!

Objectives

Identify phases of healthcare design.

Describe the nurses role in phases ofhealthcare design.

Use the evidence of healthcare design inpromoting the environment of healing.

Examine the impact of the environment on

patient safety.


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Objectives cont.

Relate the impact of the environmentaldesign on staff and patient satisfaction.

Examine the influence of healthcare designon patient care.

Examine current trends in healthcaredesign.

18th century facilities called almshouse,

Mainly served indigent, orphanages, sickwho had no place to go

Benjamin Franklin co-found PennsylvaniaHospital in 1752, UPenn now the NationsFirst Hospital to replace almshouse to

serve the poor and needy

History of Hospitals


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Took another 100 years to develop

Childrens of Philadelphia now CHOP 1855

Boston Children's opened in 1869

DC Childrens now Childrens NationalMedical Center opened 1874

Childrens Hospitals

DC Childrens Opens 1874Now ChildrensNational MedicalCenter


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Hospitals moved away from medicalexperimentation, added clinical techniquesand medical training as well as safelytreating patients in high volumes.

It was not until the late 19th Century thathospitals became part of the community anda source of civic pride

Civil War

Second largest private-sector employer inthe US and contributes nearly 2 Trillion tothe economy

Largest employer in the District ofColumbia

Teaching site for all Medical and Allied

Health professions.

Hospitals Today


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It is estimated that $100 billion in inflation-adjusted dollars has been spent on newconstruction in the past 5 years and $250billion will be spent in the next 10 years.

Clancy, 2008

Financial Impact of HealthcareDesign

The Institute of Medicine (IOM), Agency forHealthcare Research and Quality (AHRQ) andthe Joint Commission have all indicated that thework environment impacts not only patient andnurse satisfaction but also patient outcomes.


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Patient room design is extremely important becauseit is duplicated numerous times throughout thehospital environment.

Decisions made about hospital designtoday will have an impact on how care isdelivered for decades.


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Nurses are in a unique position to impactdesign decisions as:

Advocates for patients and families

Professionals who have an understanding ofprocesses that support patient care which areinfluenced by the built environment

Nurses Role


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Ideal lead for HC design why?

Knowledge base

Operational sense

Patient and family focus

Familiar with care space needs

Experience the comes with age

Leader of multidisciplinary teams

Nurses as Leaders


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Evidence Based Principles

Address high level priorities i.e. IC,Emergency preparedness, noise etc

Include Clinicians

Design Flexibility

Incorporate green principles

Address practice implications ***

Principles of Healthcare Design

Planning phase

Strategic Plan 3-5 year

Operational Plan what will we do with XXX

Financial Planning what will it cost

Approval phase

Resource allocation i.e. operating vs. bonds

Phases of HC Design


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Space plans to meet the programmaticneeds and allocation of square footage toeach space

200 Sq feet MS

250-350 Sq Feet CC

300-600 Sq Feet OR

15-20% allocation for support space - low

Space Programming


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Flexible to accommodate different ratios

Adaptable to accommodate levels of acuity

Multiple diagnosis / ages

Growth surge capacity flex up / down

Design


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Is difficult task

To large walking distance burn out

To small isolates staff, inefficient

Trend 32 bed units cost and spaceefficient

Largest recommended 54 beds

Determining Optimal Number

Centralized

Decentralized

Family support areas in room?

Visitor amenities coffee bar?

Care Delivery Models


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Targeted census productivity targets at atarget of 80% occupancy determines the # ofbeds needed:

i.e. a unit with a targeted occupancy of 22patients a day at 80% occupancy would need28 beds. (28X 80% = 22.4)

Efficiency

Critical Care at 250-300 sq feet - $1.1 M

OR at 350 sq feet 1.4 M

Medical Surgical at 150-200 sq ft - $800

These figures include support space at10-20% of total sq feet

Cost to Construction


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Floor plans for each clinical area prepared

Not final

Conceptual

CON in most regions at this point.

Schematic Design


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Room detail and surfaces in each room isdetermined

Design Development


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MOVE PLAN

Begins months before occupancy

Multidisciplinary

Sequencing of patients

Process for the move

Ancillary support

Tracking system

Occupancy Planning

Most difficult task

IT

Equipment

Floor plan facilities

Rooms

Decentralized stations

Med rooms

Education


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Technology

Phones

Computers

Tracker devices

Getwell Network

White Boards

Monitor alarms - tracking responses

EMR impact


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Healing Environment

Safety

Satisfaction

How Space Impacts Care

The notion that the physical environment hasthe potential to impact healing is not new itis as old as antiquity. Hippocrates referred tothe environment as the fourth factor followingdisease, patient and physician as contributingto healing.

J.M. Currie The Fourth Factor: A

Historical Perspective onArchitecture and Medicine

Healing Environment


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Natural light

Airiness

Cleanliness

Order

Quietness

Proper Nutrition

Florence Nightingale

Emerged from the unpleasant hospitalexperience of Angelica Thieriot in the 1970s

She founded the non-profit organizationcalled Planetree to transform healthcareexperiences

Planetree


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Planetree is relationship based care

Patient is the center of the relationship

125 hospitals are part of the Planetree Alliance

Planetree

Natural light

Elements of nature stone, wood, plants

Homelike features

Culture that honors the person as a holisticbeing with integration of mind, body andspirit

J. Stichler Healing by Design 2008

Planetree


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Exposure to nature has been demonstrated tohave calming restorative effect on pediatricpatients and their families

Views or images of nature and natural lightare associated with reduced stress andincrease pain tolerance

Exposure to view of nature positively affectscaregivers, on a daily basis it can improve

alertness and improve focus

(Debajyoti, Harvey, Barach 2008)

Access to Nature

Noise

Lighting

Infection

Single-Patient Rooms

Distance and Space

Safety


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Sound has many different manifestationsfrom disturbing and stressful to soothing andcalming

Speech is sound

Noise is unwanted sound

Hospitals are generally extremely noisy

Sound

World Health Organization (WHO) hasdefined values for background hospitalnoise in patient rooms Daytime 35 dB

Nighttime 30 dB

Busch-Vishniac (2005) reviewed 35published studies over 45 years Not one

reported noise levels the were withinWHO values

A. Joseph, R. Ulrich www.healthdesign.org

Hospital Noise


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Peak level in hospitals often reaches 85-90 dB

Motorcycle at 25 feet - 90 dB

Diesel Train at 45 miles/hour at 100 feet -83 dB

Spoken language between 40-60 dB

Normal breathing 10 dB

Busy Traffic 70 dB

Niagara Falls 90 dB

Hospital Noise

Exposure to excessive noise in NICUs impactsshort-term and long-term auditory development(NACHRI and The Center for Health Design)

Annoyance and sleep disturbance

Decreased oxygen saturation

Elevated blood pressure

Increase heart rate and respiration

Decreased rate of wound healing

A.Joseph, R Ulrich

www.healthdesign.org

Noise and Patients


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Increased stress and annoyance

Interferes with ability to work effectively

Evidence suggests that reduced noise levelsresult in more effective recall andcommunication of information and reductionin perceived work demand and pressure

Benjamin, DeWitty, Scott 2008

Noise and Staff

Effective methods to reduce noise

Sound absorbing ceiling tiles and flooring

Single patient rooms

Staff and family education related to effects ofnoise

Noise


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Patients exposed to brighter natural sunlighttook 22% less medication for pain per hour

Sufficient lighting for caregivers whencompleting complex tasks such as preparingmedications reduces errors

There is increased need for illumination withincreased age

Average age of nurse in the US is 45.2 years

Lighting

Access to Natural Light andNature


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The Joint Commission stated in its 2008HealthCare at the Crossroads: Guiding Principles forthe Development of the Hospital of the Futurethat single-patient rooms may have the singlemost important impact on patient safety .Single rooms help protect patients health.

Single Patient Rooms

Can reduce the number of transfers andhandoffs

Improve patient flow

85 beds in single patient rooms function as thesame bed capacity as 100 multi-patient bedrooms (Detsky, Etchells 2008)

Benefits of Single Patient RoomsCurrent Trends


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Infection control Decrease spread of infectious agents between

patients sharing a room

Increase visual cue for caregivers to wash handsprior and after contact with patients

Easier to decontaminate empty single patientroom than shared patient room

Benefits of Single Patient Rooms

Quieter

Privacy

Decreased interruptions promotes rest andrecovery

Supports family participation in care

Facilitates private consultations with care

providers

Benefits of Single Patient Rooms


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Decentralized work stations and supply andmedication rooms facilitate nurses being closerto patients and increase in direct-care activities

Distance and SpaceCurrent Trends

Caution: Caring for patients is a team activityrequiring official and unofficial collaborationwith other nurses and other members of themultidisciplinary team

Teamwork and communication are critical toproviding safe patient care

Decentralized work stations must be combined

with flexible spaces for interactive teamcollaboration and social interaction

Teamwork and

Collaboration


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Team/Collaborative Space

Healthcare environment must be designed forthe care giving processes

Direct correlation between staff performanceand patient safety

Poorly designed environments force work-around

70% of hospital preventable errors orpotential errors are the result of process errors

Influence of Design on Patient

Care


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No involvement of nurses or other healthprofessionals in design

Noted Defects ED and ICU rooms too small

Resuscitation room in ED does not allow staff access tohead of patient

Patients in Mental Health Unit have access to roof andcourtyard leading to 20-metre drop

Pediatric patients have access to roof with 3 story drop Maternity assessment room doorway too narrow for

stretchers

January 2008 Disastrous Opening ofBathurst Hospital in New South Wales

Rooms and units organized in an identicalmanner

Standardization fosters force functioningof routine tasks by designing theenvironment in such a way that guidescaregiver processes in the most efficient andsafe manner

Supports unit adaptability to adjust tochange in volumes or acuity

StandardizationCurrent Trends


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Same-Hand DesignBeds - oriented againstthe same wall in everyroomRooms - identical so usebecomes intuitive therefore saferCan be more expensive tobuild because each roomrequires its own plumbingand medical gas drops

Mirror-Reverse Design

Beds oriented againstopposite walls

Headwall can bestandardized to decreasevariation

Standardization

No conclusive evidence that supports same-handed rooms are safer

Suggestions

Reduce the number of rooms types to decreasevariation

Standardize same-handed rooms where chances ofcritical events are high (ED, ICU)

Standardize placement of medical gases inheadwall so that use becomes more intuitive

Standardization


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Design of space impacts the quality of nurseswork life, job satisfaction, stress andproductivity

Nurses job satisfaction has been shown to be amore important predictor for patient

satisfaction than nursing skill(Berry, Parish 2008)

Satisfaction

Environments that support active involvementby families in the care process demonstratehigher levels of satisfaction among patientsand families

Satisfaction


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LEED Leadership in Energy andEnvironmental Design

Certification is done by US Green BuildingCouncil

LEED and GreenCurrent Trends

Establish common standard of measure for agreen building

Promote integrated whole building designpractices

Stimulate green competition

Raise consumer awareness

Transform building market

(Healthcare Informatics, 2008)

Creation of LEED to:


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2008 celebrated its official designation as theworlds first LEED Platinum hospital

Dell Childrens Medical CenterAustin, Texas

Dell Childrens Medical Center


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Hospitals are major contributors to toxic waste

Intravenous bags and tubings PVC whenincinerated releases dioxin and other toxicsubstances

Wastes from body fluids, toxic cleaningsupplies and medication waste move intowater supply

Going Green

Recycle to reduceenvironmental impact

Reuse cleanablematerials

Renew usesustainable buildingmaterials

Refuse to purchase

supplies that are notbiodegradable

Reduce use of fossilfuels (promote carpools,public transportation,high efficiency bulbs,solar or wind energy tosupplement energysupplies, rainwatercollection)

The Rs of going Green


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Cost savings if able to reduce energydemands

Water consumption through rainwater storageand drought resistant landscaping can reduceconsumption by 30%

Natural lighting reduces energy use

Advantages of Going Green

Helps hospitals align their actions with theirmission to improve the health of thecommunity they serve

Going Green


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Conclusion

New Design

understanding healthcare design: designing patient care spaces that work

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