Understanding Healthcare Design – Designing Spaces that Work

Jesus Cepero, MSN, MPA, RN, NEA- BC
Vice President, Critical Care and Heart Institute Children’s National Medical Center, Washington, D.C.

Rose Szeles, MS, RN, NE-BC
Manager Professional Nursing Practice Children’s 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 to get it right!

Objectives
Identify phases of healthcare design. Describe the nurse’s role in phases of healthcare design. Use the evidence of healthcare design in promoting the environment of healing. Examine the impact of the environment on patient safety.

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Objectives cont.
Relate the impact of the environmental design on staff and patient satisfaction. Examine the influence of healthcare design on patient care. Examine current trends in healthcare design.

History of Hospitals
18th century facilities called “almshouse”, Mainly served indigent, orphanages, sick who had no place to go Benjamin Franklin co-found Pennsylvania Hospital in 1752, UPenn now the Nation’s First Hospital – to replace almshouse to serve the poor and needy

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Children’s Hospitals
Took another 100 years to develop
Children’s of Philadelphia now CHOP 1855 Boston Children's opened in 1869 DC Children’s – now Children’s National Medical Center opened 1874

DC Children’s – Opens 1874
Now Children’s National Medical Center

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Civil War
Hospitals moved away from medical experimentation, added clinical techniques and medical training as well as safely treating patients in high volumes. It was not until the late 19th Century that hospitals became part of the community and a source of civic pride

Hospitals Today
Second largest private-sector employer in the US and contributes nearly 2 Trillion to the economy Largest employer in the District of Columbia Teaching site for all Medical and Allied Health professions.

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Financial Impact of Healthcare Design
It is estimated that $100 billion in inflationadjusted dollars has been spent on new construction in the past 5 years and $250 billion will be spent in the next 10 years.
Clancy, 2008

The Institute of Medicine (IOM), Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission have all indicated that the work environment impacts not only patient and nurse satisfaction but also patient outcomes.

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Patient room design is extremely important because it is duplicated numerous times throughout the hospital environment.

Decisions made about hospital design today will have an impact on how care is delivered for decades.

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Nurses’ Role
Nurses are in a unique position to impact design decisions as:
Advocates for patients and families Professionals who have an understanding of processes that support patient care which are influenced by the built environment

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Nurses as Leaders
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

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Principles of Healthcare Design
Evidence Based Principles Address high level priorities i.e. IC, Emergency preparedness, noise etc Include Clinicians Design Flexibility Incorporate “ green “ principles Address practice implications ***

Phases of HC 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

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Space Programming
Space plans to meet the programmatic needs and allocation of square footage to each space
200 Sq feet – MS 250-350 Sq Feet – CC 300-600 Sq Feet – OR 15-20% allocation for support space - low

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Design
Flexible to accommodate different ratio’s Adaptable to accommodate levels of acuity Multiple diagnosis / ages Growth – surge capacity – flex up / down

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Determining Optimal Number
Is difficult task
• To large – walking distance burn out • To small – isolates staff, inefficient

Trend 32 bed units – cost and space efficient Largest recommended 54 beds

Care Delivery Models
Centralized Decentralized Family support areas in room? Visitor amenities – coffee bar?

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Efficiency
Targeted census – productivity targets at a target of 80% occupancy determines the # of beds needed: i.e. a unit with a targeted occupancy of 22 patients a day at 80% occupancy would need 28 beds. (28X 80% = 22.4)

Cost to Construction
• 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 at 10-20% of total sq feet

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Schematic Design
Floor plans for each clinical area prepared Not final Conceptual CON in most regions at this point.

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Design Development
Room detail and surfaces in each room is determined

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Construction Documents
Guides construction
Architectural design Plumbing Electrical HVAC

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Occupancy Planning
MOVE PLAN
Begins months before occupancy Multidisciplinary Sequencing of patients Process for the move Ancillary support Tracking system

Education
Most difficult task
IT Equipment Floor plan – facilities Rooms Decentralized stations Med rooms

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Technology
Phones Computers Tracker devices Getwell Network White Boards Monitor alarms - tracking responses EMR impact

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How Space Impacts Care
Healing Environment Safety Satisfaction

Healing Environment
The notion that the physical environment has the potential to impact healing is not new – it is as old as antiquity. Hippocrates referred to the environment as the fourth factor following disease, patient and physician as contributing to healing.
J.M. Currie The Fourth Factor: A Historical Perspective on Architecture and Medicine

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Florence Nightingale
Natural light Airiness Cleanliness Order Quietness Proper Nutrition

Planetree
Emerged from the unpleasant hospital experience of Angelica Thieriot in the 1970’s She founded the non-profit organization called Planetree to transform healthcare experiences

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Planetree
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 holistic being with integration of mind, body and spirit

J. Stichler Healing by Design 2008

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Access to Nature
Exposure to nature has been demonstrated to have calming restorative effect on pediatric patients and their families Views or images of nature and natural light are associated with reduced stress and increase pain tolerance Exposure to view of nature positively affects caregivers, on a daily basis it can improve alertness and improve focus
(Debajyoti, Harvey, Barach 2008)

Safety
Noise Lighting Infection Single-Patient Rooms Distance and Space

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Sound
Sound has many different manifestations from disturbing and stressful to soothing and calming Speech is sound Noise is unwanted sound Hospitals are generally extremely noisy

Hospital Noise
World Health Organization (WHO) has defined values for background hospital noise in patient rooms
• Daytime – 35 dB • Nighttime – 30 dB

Busch-Vishniac (2005) reviewed 35 published studies over 45 years – Not one reported noise levels the were within WHO values

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

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Hospital Noise
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

Noise and Patients
Exposure to excessive noise in NICU’s impacts short-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

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Noise and Staff
Increased stress and annoyance Interferes with ability to work effectively Evidence suggests that reduced noise levels result in more effective recall and communication of information and reduction in perceived work demand and pressure
Benjamin, DeWitty, Scott 2008

Noise
Effective methods to reduce noise
Sound absorbing ceiling tiles and flooring Single patient rooms Staff and family education related to effects of noise

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Lighting
Patients exposed to brighter natural sunlight took 22% less medication for pain per hour Sufficient lighting for caregivers when completing complex tasks such as preparing medications reduces errors There is increased need for illumination with increased age • Average age of nurse in the US is 45.2 years

Access to Natural Light and Nature

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Single Patient Rooms
The Joint Commission stated in its 2008 Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future that single-patient rooms may have the single most important impact on patient safety …. Single rooms help protect patients’ health.

Benefits of Single Patient Rooms
Current Trends Can reduce the number of transfers and handoffs Improve patient flow
• 85 beds in single patient rooms function as the same bed capacity as 100 multi-patient bed rooms (Detsky, Etchells 2008)

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Benefits of Single Patient Rooms
Infection control
• Decrease spread of infectious agents between patients sharing a room • Increase visual cue for caregivers to wash hands prior and after contact with patients • Easier to decontaminate empty single patient room than shared patient room

Benefits of Single Patient Rooms
Quieter Privacy Decreased interruptions – promotes rest and recovery Supports family participation in care Facilitates private consultations with care providers

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Distance and Space
1996 time and motion study of more than 1,000 hours on a medical/surgical nursing unit over 18 months demonstrated that total time ALL health care workers (not just nurses) spent in patient rooms ranged from 1.1 to 3.3 hours in a 12 hour shift. Majority of time was spent walking between patient rooms, nurses stations or other supply areas (med room, supply room)
IOM, Keeping Patients Safe 2004

Distance and Space
Most older existing hospitals have racetrack or single or double corridor with a central nursing station
• This configuration locates nursing staff away from patients

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Distance and Space
Current Trends Decentralized work stations and supply and medication rooms facilitate nurses being closer to patients and increase in direct-care activities

Teamwork and Collaboration
Caution: Caring for patients is a team activity requiring official and unofficial collaboration with other nurses and other members of the multidisciplinary team Teamwork and communication are critical to providing safe patient care Decentralized work stations must be combined with flexible spaces for interactive team collaboration and social interaction

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Team/Collaborative Space

Influence of Design on Patient Care
Healthcare environment must be designed for the care giving processes Direct correlation between staff performance and patient safety Poorly designed environments force workaround 70% of hospital preventable errors or potential errors are the result of process errors

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January 2008 – Disastrous Opening of Bathurst Hospital in New South Wales
No involvement of nurses or other health professionals in design Noted Defects
– ED and ICU rooms too small – Resuscitation room in ED does not allow staff access to head of patient – Patients in Mental Health Unit have access to roof and courtyard leading to 20-metre drop – Pediatric patients have access to roof with 3 story drop – Maternity assessment room doorway too narrow for stretchers

Standardization
Current Trends Rooms and units organized in an identical manner Standardization fosters “force functioning” of routine tasks by designing the environment in such a way that guides caregiver processes in the most efficient and safe manner Supports unit adaptability to adjust to change in volumes or acuity

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Standardization
Same-Hand Design Beds - oriented against the same wall in every room Rooms - identical so use becomes intuitive – therefore safer Can be more expensive to build because each room requires its own plumbing and medical gas drops Mirror-Reverse Design Beds – oriented against opposite walls Headwall can be standardized to decrease variation

Standardization
No conclusive evidence that supports samehanded rooms are safer Suggestions
• Reduce the number of rooms types to decrease variation • Standardize same-handed rooms where chances of critical events are high (ED, ICU) • Standardize placement of medical gases in headwall so that use becomes more intuitive

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Satisfaction
Design of space impacts the quality of nurses’ work life, job satisfaction, stress and productivity Nurses’ job satisfaction has been shown to be a more important predictor for patient satisfaction than nursing skill
(Berry, Parish 2008)

Satisfaction
Environments that support active involvement by families in the care process demonstrate higher levels of satisfaction among patients and families

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LEED and Green
Current Trends
LEED – Leadership in Energy and Environmental Design Certification is done by US Green Building Council

Creation of LEED to:
Establish common standard of measure for a “green building” Promote integrated whole building design practices Stimulate green competition Raise consumer awareness Transform building market
(Healthcare Informatics, 2008)

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Dell Children’s Medical Center Austin, Texas
2008 – celebrated its official designation as the world’s first LEED Platinum hospital

Dell Children’s Medical Center

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Going Green
Hospitals are major contributors to toxic waste Intravenous bags and tubings – PVC – when incinerated releases dioxin and other toxic substances Wastes from body fluids, toxic cleaning supplies and medication waste move into water supply

The R’s of going Green
Recycle – to reduce environmental impact Reuse – cleanable materials Renew – use sustainable building materials Refuse – to purchase supplies that are not biodegradable Reduce – use of fossil fuels (promote carpools, public transportation, high efficiency bulbs, solar or wind energy to supplement energy supplies, rainwater collection)

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Advantages of Going Green
Cost savings – if able to reduce energy demands Water consumption through rainwater storage and drought resistant landscaping – can reduce consumption by 30% Natural lighting reduces energy use

Going Green
Helps hospitals align their actions with their mission to improve the health of the community they serve

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Conclusion

New Design

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