Safety, Efficiency and Flexibility – Convergent or Mutually Exclusive Goals in Healthcare Design

Paul Barach, MD, MPH Clalit Seminar October 1 2013

Wellness Model

Components of Evidence based Quality/Design












Looking for Harm

Active Event Reporting

Truth? Passive Indicators Discharge Data Passive Triggers Medical Records

How Safe is Safe Enough ???

How Does 99.9% Sound?

Assuming a system is 99.9% safe, what does that mean in the real world ?
•! 84 unsafe landings /day •! 1 major plane crash every 3 days •! 16,000 mail items lost/hr •! 37,000 bank transaction errors/hr

Adverse Event Rates in Healthcare
Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safe Health Care. Annals of Internal Medicine, 2005;142:756-764.

No system beyond this point

Fatal Iatrogenic adverse events Cardiac Surgery Patient ASA!3-5 Microlight flights helicopters Medical risk (total)

Blood transfusion Anesthesiology ASA1 Civil Aviation

Himalaya mountaineering

Chartered Flight Road Safety Chemical Industry (total)

Railways (France)

Nuclear Industry

Very unsafe







Ultra safe

Minor Adverse Events and Patient Satisfaction After Anaesthesia:A Prospective Interview Study
Michael Lehmann, Kai Monte, Paul Barach, Christoph Kindler, MD JCA, 2010

!!12, 347 cases; 29% minor adverse event that cause much unhappiness and dissatisfaction, yet are not long lasting or permanent. !!These minor events, however, cause much delay in healing and are an added expense to the cost of healthcare.


operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through Wednesdays: 2.94% vs. 2.18%;
Odds ratio, 1.36; 95% CI, 1.24–1.49)


Mental Models
"!Our personal image of the world
•! None are perfectly accurate •! Differences in mental models explain how two people can understand the same event differently •! Are generally invisible to us – until we look for them


The Ladder of Inference
(Peter Senge)

Risk Model

If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made Norman, The Design of Everyday Things, 2001

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System Factors That Impact Safety
Barach P & Small. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759-763

Staff Individual Factors Patient Intrinsic Factors Team factors

National Culture Organisation Factors Technical Factors

Individual Factors

Solet J. and Barach P., 2012

Human Factors : Re-engineering the perioperative process
•! Improve processes •! Improve ergonomics •! Integrate technologies •! Optimize patient safety •! Increase throughput •! Improve staff satisfaction •! Maintain protected research environment
•! Bedside surgical interface •! Optimized monitor placement •! Develop smart alarms and automated clinical decision support •! Develop interlocks across medical device systems •! Benefit of medical device interoperability •! Synchronization to mitigate hazard

Reason – Complex Systems

HH: hand hygiene. OT: operating theatre. NSG: non-sterile gloves. SG: sterile gloves

Annelot C Krediet, et al. Hygiene Practices in the Operating Theatre: An Observational Study., BJA, 2011

60% 50%

Preliminary Findings (Quan and Ulrich,
2005) 74%

total increase

Handwashing rate

40% 30% 20% 10% 27% 0% 38% 47%
42% increase 28% increase

Open bay

Old single room

New single room

Medication Dispensing Error Rates by Illumination Level (Buchanan et al., 1991)

4.25% 4.00% 3.75% 3.50% 3.25% 3.00% 2.75% 2.50% 2.25%

Error Rate

250 lux

480 lux

1100 lux

1550 lux

(Lighting on task, not ambient)

Coping with innovation
•! How we make decisions – optimizing vs. sacrificing •! Spanning silos •! Testing new ideas •! Late binding •! Confronting conflicts •! What if we’re wrong? •! How does lean fit into this process?

Hybrid Operating Room Defined Procedure room designed for: #! “open” and/or “closed” surgical procedures #! configured for surgical sterile control precautions, including the establishment of a “surgical red-line” of demarcation #! use of anesthesia #! advanced image-guidance

Key Design Challenges

#! Future flexibility #! Turf battles / decision-making #! Available space, infrastructure, capital #! Integration of clinical devices #! Design for Surgery vs. Interventional Procedures
Image, courtesy of Stantec

Designing for Function and Flexibility
•! The Concept of the ‘Interventional Platform’ •! Communication strategy at multiple levels and scales •! Tools to facilitate understanding

The ‘Interventional Platform’
Realigning the Silos

Technology Based
Surgery Interventional Imaging Cardiac Catheterization Endoscopy (natural orifice access)

Systems Based
Brain Head and Neck Lung Heart Vasculature Breast Bone Intestine Kidney and Bladder

The ‘Interventional Platform’
Shared Services

Registration Family Waiting Pre-Op/PACU Anesthesia Pathology Central Supply

Scheduling Clear Wayfinding Reduce positions Colocation of staff

Colocation of staff Reduce space

The ‘Interventional Platform’
Flexible Technology

The ‘Interventional Platform’
Flexible Space

The ‘Interventional Platform’
Flexible Services

The ‘Interventional Platform’
Flexible Dimensions

Flexibility Strategies

Suite Design Strategies

Room Design Strategies

Communications Strategy I
Consensus Building
Vision (from the top) Alignment of Surgery/ Medicine Alignment of Surgery/ Radiology Cardiac Catheterization buy in Playing by Surgical Rules Code/Operational Issues Culture Shock




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Communications Strategy II
Scales of Consensus
The Big Idea (guiding principles) Change management as normative (big idea) Establishing a new hierarchy Understanding group and individual loss Leveling an unlevel playing field Establishing small group alliances

Tools to Facilitate Understanding
Steps from the beginning

Program (numbers and narrative) Adjacency and Flow Diagrams Plans and Reflected Ceiling Plans Elevations and Equipment Placement 3D Modeling and Scale Models Full Scale Models and Simulation Mock-ups with Equipment and Finishes

Tools to Facilitate Understanding
Plans and Reflective Ceiling Plans

Tools to Facilitate Understanding
3D Modeling

Tools to Facilitate Understanding
3D Modeling

Tools to Facilitate Understanding
3D Modeling

Tools to Facilitate Understanding
3D Modeling

Tools to Facilitate Understanding
Full Scale Models and Simulation

Results -Safety Culture in the OR
•! 3 academic PCS teams were surveyed on:
•! Adverse event reporting •! OR management •! Safety culture

•! 72% response rate •! Significant differences (p<0.001) between both institutions regarding communication at all levels •! 45% felt that outcomes were not safe •! 33% felt that errors of the same kind keep on recurring •! 47% felt that administration was not sensitive to patient safety issues

Bognar A et al, Annals of Surgery, 2008

Stages in the development of a safety culture
GENERATIVE (High Reliability Orgs)! HSE is how we do business! round here! PROACTIVE! Safety leadership and values drive continuous improvement! CALCULATIVE! We have systems in place to! manage all hazards! REACTIVE! Safety is important, we do a lot! every time we have an accident! PATHOLOGICAL! Who cares as long as! we're not caught!

Adapted from Westrum (1992, 2000

Model of Big 5 Teamwork
Team Leadership

Team Orientatio n

Mutual Performance Monitoring

Back-Up Behavior

Adaptabilit y

Baker, Salas, King, Battles, Barach, 2006

Health care consumes 18% of US energy annually

© 2009 Perkins+Will

Slide: 51

The Impact of Design on EBD Outcomes

Source: Healthcare Leadership white Paper: Ulrich, Zimring, Zhu, DuBose, Seo, Choi, Quan, Joseph (2008) http: // 5 LitReviewWP.pdf

High-Priority Research Directions for Seeking to Built Safer and Sustainable Facilities


Design of Cardiovascular Operating Rooms for Tomorrow’s Technology and Clinical Practice – Part One;
B. Rostenberg, P. Barach; Progress in Pediatric Cardiology; 32 (2011) 121-128



Design of Cardiovascular Operating Rooms for Tomorrow’s Technology and Clinical Practice – Part Two;
B. Rostenberg, P. Barach; Progress in Pediatric Cardiology; 33 (2012) 57-65


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