geometry of clinical efficiency

participants Steven M. Langston AIA, ACHA, EDAC, LEED AP RLF Healthcare Susan O Hara RN, MPH O Hara HealthCare Vincent Della Donna AIA RLF Healthcare

learning objectives 1 Identify evidence based design research components and approaches. 2 Compare and contrast different triangular nursing unit models and their components. 3 Learn about how geometry effects the efficiency of a nursing unit. 4 Understand the effects on nursing care relating to the functional use of the healthcare environment.

scope of study 1 Review of existing literature and research 2 Review of built examples of triangular units 3 Development of triangular variations and component arrangements 4 Time + distance measurements of selected units 5 Lean Design Analysis through Simulation Modeling

background 1 Keesler Community Hospital 2 MD Anderson Cancer Center Orlando Keesler AFB Hospital - Biloxi, MS RLF MD Anderson Cancer Center Orlando - Orlando, FL RLF

research introduction What is the most efficient triangular unit? research question Research existing triangular units. Research evidence-based design findings. pilot study What is quantifiably measurable? Compared to what? Benchmarks? redefine process Which units are most effective + why? measure + evaluate

define efficiency efficiency [ih-fish-uhn-see] : the ability to complete a task with minimal waste. effectiveness [ih-fek-tiv-nes] : the ability to accomplish a purpose. What makes a patient unit most efficient and effective?

measurement criteria purpose: objectives: to have positive medical outcomes while reducing costs. safety healing environment optimize work flow flexibility minimize walking distances noise distractions medical errors stress waste infections falls/injuries movement/transfers cross-circulation maximize visibility wayfinding standardization Communication / collaboration natural light / views pleasant distractions environmental choices privacy social support adaptability / expandability

efficient for who? 1 nurses 2 physicians 3 administration 4 allied health professionals how they spend their time 5.6% patient access 15% patient care 27.4% documentation 5 patients 6 visitors/family 7 maintenance/facilities Nurse s Time Diagram from Design Dilemma Nurse Station Study Y Chiang 13.3% medication 16% coordination 12.6% non-clinical 2.8% unrelated 6.6% waste

what is a triangular unit? rectangle circular t or cross triangle

triangular unit examples 90 degree joined Travis AFB Hospital - Travis, CA xxx

triangular unit examples 90 degree Kaiser Permanente Antioch - Antioch, CA Smith Group

triangular unit examples 90 degree convex Keesler Community Hospital Biloxi, MS RLF

triangular unit examples 90 degree convex MD Anderson Cancer Center Orlando Orlando, FL RLF

triangular unit examples 90 degree concave Beaumont Hospital North Pavilion - Detroit, MI HOK

triangular unit examples convex + 90 degree Ronald Reagan Memorial Hospital - Los Angles, CA Perkins + Will

triangular unit examples bowtie Baylor Plano Heart Hospital - Plano, TX RTKL

triangular unit examples complex hybrids Conceptual Cardiac Hospital Addition, Orlando, FL RLF

triangular unit examples complex hybrid Rush Medical Center Chicago, IL Perkins + Will

triangular unit examples complex hybrid Ronald Reagan Memorial Hospital - Los Angles, CA Perkins + Will

what is a triangular unit? A patient care unit composed of a closed three sided shape with patient rooms located along each side. rectangle circular t or cross triangle

how does the geometry effect the efficiency of a unit? 1 Organizational culture 2 Work Processes 3 Technology One-time documentation Efficient patient assignments Open communication work processes 4 Physical Design Electronic records Connected systems technology infrastructure organizational structure Autonomy Collaboration Respect Nurse retention Less stress More patient care time Improved safety Reduced risk of errors EOC Diagram from Design Dilemma Nurse Station Study Y Chiang physical design Visibility Supply locations Varied work spaces privacy

assumptions Evidence Based Design: Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. For healthcare, the goal is to achieve the best possible outcomes for patients/residents, families, and staff while improving the process of delivery. 1 Patient Room Configuration 2 Nurse Station Model 3 Support Configuration 4 Waiting / Family Support 5 Circulation

assumptions circulation design features Public circulation located on axis with the main nursing station. Visibility of other nursing stations from main nursing station. Patient and service elevators located within the core. Exit stairs located along the back two points of the racetrack. Circulation paths treated differently.

assumptions nursing station configuration design features De-centralized hybrid model. Visibility of rooms, circulation and peers. Main nurse station across from public circulation. Vary level of immersion w/ different station points. De-centralized supplies near station + rooms.

assumptions patient rooms design features Flexible room assignment ratios. Acuity adaptable. Nurse perches w/ view windows. De-centralized supplies at room. Visibility into rooms from nurse station.

assumptions support configuration design features Support services located within the central core. De-centralized supplies at rooms + nurse stations. Leverage technology for tracking + re-stocking. Large central meeting/conference space. Respite + meeting spaces located off-stage in core.

assumptions waiting + family support design features Family waiting located along the exterior. Nourishment centers + information at each space. Access to natural light and views. Convenient to nursing station + consult rooms.

space program 24 30 32 36 40 public patient support admin

what and how are we measuring 1 Efficiency area, distances + workflow 2 Effectiveness - prioritized objectives 3 Design assumptions based on peer-reviewed Evidence Based Design findings 4 Compared with national benchmarking standards 5 Simulation Modeling

conceptual triangular unit geometry studies

conceptual triangular unit geometry studies circulation visibility area circulation visibility area circulation visibility area circulation visibility area

evaluation tool safety healing environment optimize workflow flexibility

conceptual triangular unit geometry studies

results recommendations 1 Smaller units using flexible divisions of twelve rooms. 2 Acuity adaptable: larger rooms, increased visibility + support. 3 Decentralized nursing station placed at circulation points. 4 Provide multiple flexible work + observation places: public + private. 5 Allow visibility of peers to peers: enhancing wayfinding + support. 6 Separate public + service circulation paths. 7 Provide collaborative staff spaces: bump spaces to privacy. 8 Provide multiple levels of family + respite space throughout the unit.

triangular unit geometry studies 90* - 24 room t t fam m n eq c o t cl sl n c m r t l j eq n m c day c

questions?

references 1 Hendrich AL, Fay J, Sorells A. Effects of acuity adaptable rooms on flow of patients and delivery of care. American Journal of Critical Care. 2004. 2 Hendrich A, Nyhuis A, Kippenbrock T, Soja ME. Hospital falls: development of a predictive model for clinical practice. Appl. Nurs. Res. 1995. 3 Brown KK, Gallant D. Impacting Patient Outcomes through design: acuity adaptable care/universal Room Design. Critical Care Nursing Quarterly. 2003. 4 Joseph A, Rahid M. The architecture of safety: hospital design. Curr. Opin Crit Care, 2007. 5 Ulrich RS, Zimring C, Joseph A, et al. The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity. The Center for Health Design, 2004. 6 Facilities Guidelines Institute. Guidelines for design and construction of healthcare facilities. Washington, DC: The American Institute of Architects; 2010. 7 Joint Commission on Accreditation of Healthcare Organizations. Root causes of patient falls. Sentinel event statistics 2006. http://www.jointcommission.org 8 Hendrich A, Lee N. Intra-unit patient transports: time, motion, and cost impact on hospital efficiency. Nurs Econ 2005. 9 Joseph A. The impact of the environment on infections in healthcare facilities. The Center for Health Design; 2006. 10 Hamilton K Design for flexibility in critical care. Proceedings of ICU 2010

references 11 Shepley MM, Davies K. Nursing unit configuration and its relationship to noise and nurse walking behavior: an AIDS/HIV unit case study. AIA Academy Journal; 2003. 12 Uhlig P. Reconfiguring clinical teamwork for safety and effectiveness: focus on patient safety. Indianapolis: National Patient Safety Foundation; 2002. 13 Sadler BL, DuBose R, Malone EB, Zimirig CM. The business case for building better hospitals through evidence-based Design. Center for Health Design 2002. 14 Page, A. Keeping Patients Safe: transforming the work environment of nurses. Institute of Medicine Report The national academies Press. 2004. 15 HRSA, Bureau of Health Professionals. Workflow analysis: projected supply and shortage of registered nurses: 2000-2020. National Center of Health. 16 Hendrich A, Chow MP,Skierczynski B, Lu Z. A 36 hospital time and motion study: how do medicalsurgical nurses spend their time? Permanente Journal 12, 2008. 17 Institution of Medicine. Keeping patients safe: transforming the work environment of nurses. The national academies Press 2004. 18 Hendrich A, Lee N. Intra-unit patient transports: time, motion and cost impact on hospital efficiency. Nursing economics 23, 2005. 19 Bromberg J. Planning and Designing highly functional nurse s stations. Healthcare design magazine. June 2006.