Innovative Nursing Unit Designs Evaluated Over Time

Innovative Nursing Unit Designs Evaluated Over Time A Post-Occupancy Review of Mercy Heart Hospital Nursing Unit Presenters: Jeff Johnston, President, Mercy Hospital, St Louis John Reeve AIA, Principal, Christner Architects March 23, 2016 1

Presentation Objectives: Discuss the value and challenges of Post Occupancy studies Review nature of evidence for assessing design performance Report findings of performance of design innovations Propose framework for evaluating innovation cost/benefit 2

Mercy Health Where We Serve 3

Mercy St. Louis, System Flagship Hospital 859 Staffed Beds 86,985 ED Visits 6,346 Co-Workers 892,172 Outpatient Visits 425 Integrated Physicians 8,598 Births 41,165 Discharges 31,532 Surgeries LeapFrog Hospital Health Grades Top 50 Truven Heart Hospital 4

Creating A Destination for Heart Health Mercy St Louis Master Plan: 2001 Pratt Cancer Center 2002 Mercy Heart Hospital pavilion designed: 2004 Heart Pavilion occupied: 2007 First post-occupancy evaluation: 2007 Second P.O. evaluation: 2008 Children s Pavilion 2010 Third P.O. Review: 2015 Heart Hospital Design New Heart Hospital completion 2 nd Post Occupancy Evaluation Children s Hospital 2001 2004 2006 2007 2008 2010 2015 Mercy (St John s) Hospital Master Plan Evaluation of original Pinwheel tower 1 st Post-Occupancy Evaluation Post-Occupancy Review 5

Post-Occupancy Evaluations Value for Effort? Measure conformance with design requirements Adapt to changing organizational needs Test premises that justify a repetitive design solution Understand impact on occupants/users Determine how well a concept works Justify design expenditures (cost/benefit) Improve operational performance 2 Wolfgang F.E. Preiser, The Evolution of Post-Occupancy Evaluation: Toward Building Performance and Universal Design Evaluation, in Learning from Our Buildings: A State-of-the-Practice Summary of Post-Occupancy Evaluation, (Washington D.C.: National Academy Press, 2002), 11. 6

Heart & Vascular Hospital Building Concept Destination for Heart Health Elevate visibility, recognition Integrate clinical services Optimized performance Improve patient satisfaction Provide for flexible growth 7

Heart Hospital Market Success 49,000 48,000 47,000 46,000 45,000 44,000 43,000 42,000 41,000 Total Procedure Volume 47,696 47,074 44,812 43,249 2012 2013 2014 2015 3% average/ annum 8

Heart Hospital Nursing Floor 32 acuity adaptable private patient rooms (3 floors) Third (center) corridor = 1,400 sf; (6% increase) Each NS serves 4 private rooms Elevators off unit 9

Previous Studies: Assess 6 Design Goals 1. Superior work environment 2. Superior healing environment 3. Greater staff efficiency 4. Increased patients privacy 5. Facility flexibility 2007/08 Press-Ganey 2007 2008 6. Supportive family spaces 10

Current (2015) Study Objectives: Have previous conclusions held up? Are performance goals still being met? Were design innovations worth the investment? What conclusion guide us going forward? 11

Methodology for Evaluation Data Collection 1 Reviewing previous studies ( 07, 08); acoustical readings, HCHAPS, Relevant performance statistics Interviews & Surveys 2 Interview & survey nursing staff Interview Patient Advocates Observation & Mapping 3 Observations nursing time distribution, trip patterns, Analysis 4 Cost Premium, acoustics, HCAHPS Findings 5 Lessons Learned Management, operations, capital planning, design 12

Two Planning Strategies to Evaluate 1. Triple Corridor Hypothesis: HCHAP: Quietness Reduce noise @ patient room Quieter environment: better sleep, quicker recovery Potential: reduction ALOS and increase patient satisfaction Challenge/Risk: Required space: 1400 sq. ft. Increase initial cost project cost 2. Distributed Nursing & Supply Hypothesis: HCHAP: Responsiveness Reduced noise from confidential and casual staff conversation Increase nurse access to patient Outcome: increase staff efficiency and patient satisfaction Challenge/Risk: Nurse acceptance Nursing effectiveness 13

New Motivation: HCHAPS HCHAPS Patient Questionnaire YES/ALWAYS Quality of Communications with Nurses 77% Quality of Communications with Doctors 80% Responsiveness of Hospital Staff 65% Quality Pain Management 70% Communications about Medicines 61% Cleanliness of Hospital Environment 72% Quietness of Hospital Environment 59% Complete Discharge Information 83% Overall Rating of Hospital 68% Recommend Hospital 70% HCHAPS Survey: US Results 2010-11 3851 hospitals; 2,786,920 surveys 14

HCHAPS Quietness Criteria The Research is unambiguous: hospital patients queried in recent surveys cited noise as a major factor negatively affecting their quality of care. 15

Basic Noise Reducing Strategies Source Mitigation: Construction Details: Functional Planning: Transmission Absorption: 16

Planning Strategy Loud vs Quiet Corridors Quiet Corridor limited circulations for providers Loud Corridor general circulation, staff, visitors, support Third Corridor = 1,400 sf; 45 dgsf per room; (6%) 17

Reduced Noise Levels Preliminary Readings Hand held sound meter 70 65 60 55 50 45 40 35 30 db 64 52 Nurse Station 41 40 50 50 45 38 51 db 60 55 50 45 40 35 30 Pinwheel Hospital 56 Heart Hospital - 2015 44 Patient Room Pinwheel Hospital Heart Hospital - 2015 40 52 Sound Levels Avg. db 48 Relative db Scale of Common Sounds Recording Studio 30 db Home bedroom 40 db Average home 50 db Normal Conversation 60 db Car 70 db Busy arterial traffic 80 db Hair Drier 90 db 18

Acoustical Data Collection Sonicu Relative db Scale of Common Sounds Recording Studio 30 db Home bedroom 40 db Average home 50 db Normal Conversation 60 db Car 70 db Busy arterial traffic 80 db Hair Drier 90 db 19

Sound Readings -2015 Heart Hospital Pinwheel 50 dba 42 dba db 48 46 44 42 40 38 36 34 32 30 46 Background Sound Levels 40 48 46 44 42 40 38 36 34 32 30 Patient Room Pinwheel Hospital Heart Hospital - 2015 db 47 42 Nurse Station Every 10 dba increase = double perceived sound 20

Nursing Stations Sound Readings Nighttime Heart Hospital Old Unit -- Pinwheel 70 dba 55 dba 55 dba 55 dba 55 dba 21

Patient Room Sound Readings Nighttime, Heart Hospital Old Unit -- Pinwheel 70 dba 70 dba 55 dba 55 dba 55 dba Maximum acceptable sound level for Hospital Room: 35 db Acoustical Society of America 22

HCHAPS Score Comparison 75 70 65 HCHAPS Quiet Score 71.1 65.8 66 64.9 70 72 Industry Best 60 55 58.2 60.8 60 59 Industry Average 2015 50 FY13 FY14 FY15 YTD 16 HH PW 23

Survey results Assessment of Triple Corridor It s much quieter, however, families often congregate in the patient corridors and have to be asked to move to the patient rooms It is definitely quieter for both patients and nurses. Center isle reduces traffic in front of patient rooms The triple corridor is great for people who are familiar with the unit, but can be confusing for visitors N/A 8% Strongly Agree 12% Disagree 21% Neutral 13% Agree 46% The triple corridor layout is confusing for visitors. 24

Total Premium for Triple Corridor (3 floors, 96 beds) Construction SubTotal $6,308,634 $248,275 $6,556,908 % Based Soft Costs $946,295 $37,241 $983,536 Total Const. Costs $7,254,929 $285,516 $7,540,445 $1,450,986 $0 $0 Variable Soft Costs Owner Directs: FFE, Medical Equip etc Total Project Costs $8,705,915 $285,516 $7,540,445 Incremental Premium per Nursing Floor Design and Preconstruction Services, Contingency, Etc. 3% $856,548 Cost Impact for 96 Beds $130,000,000 $856,548 Incremental Premium For Heart Hospital Three Nursing Floors 96 Beds 0.66% 25

Cost Premium for Triple Corridor per Patient-day Total Capital Premium $856,548 30 Year Amortization/Depreciation Yearly Cost 96 beds Annual Patient Days (80% occupancy) $55,680 28,032 days Premium per Patient Day < $2 < 0.08% Based on average $2,300 per day cost 26

Counter Argument: Capital Cost vs. Opportunity Cost 27

New Motivation: HCHAPS HCHAPS Patient Questionnaire YES/ALWAYS Quality of Communications with Nurses 77% Quality of Communications with Doctors 80% Responsiveness of Hospital Staff 65% Quality Pain Management 70% Communications about Medicines 61% Cleanliness of Hospital Environment 72% Quietness of Hospital Environment 59% Complete Discharge Information 83% Overall Rating of Hospital 68% Recommend Hospital 70% HCHAPS Survey: US Results 2010-11 3851 hospitals; 2,786,920 surveys 28

Design Strategy Distributed Nursing 1 2 3 4 1 2 3 4 29

Design Strategy Distributed Supply Rooms Travel time per 24 hours 60% Med Room 50% 40% 30% 20% 57% 39% 10% db 0% Travel/24hours 1 2 34 Pinwheel Hospital Heart Hospital - 2015 Nurse Station Clean Soiled Linen Nurse Station 30

Zettler Report Tracks Every Event 31

HCHAPS Staff Responsiveness 3/14/16 100 90 80 70 60 50 40 30 20 10 0 Responsiveness % Always Trauma Surg Pinwheel SPCU/CVICU HH 64.75 67.3 69.6 64.3 68.25 65.85 58.9 59.3 FY2013 FY2014 FY2015 FY2016 65 Industry Average 2015 During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? 100 90 80 70 60 50 40 30 20 10 0 62.3 59.2 Call Button % Always 57 50.9 64.8 58.9 54 53.5 FY2013 FY2014 FY2015 FY2016 Trauma Surg Pinwheel SPCU/CVICU HH How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? 100 90 80 70 60 50 40 30 20 10 0 67.2 Bathroom % Always 75.4 71.6 66.9 74.4 77.6 77.7 FY2013 FY2014 FY2015 FY2016 65.1 Trauma Surg Pinwheel SPCU/CVICU HH

Survey Results: Nursing Efficiency NS Configuration Works well as a single nurse to patient unit, but feels spread out in terms of accessibility to other nurses It s sometimes hard to find help, but the pod layout is better than a central nursing station. It saves lots of walking time Right now the staff rounds in the hallway to keep an eye on patients. This poses a privacy issue. Disagree 8% N/A 8% Strongly Agree 17% Neutral 8% Agree 59% Nurse stations facing patient rooms would improve my ability to provide patient care. 33

Survey Results: Staff Satisfaction Works well as a single-nurse-to-patient unit, but feels spread out in terms of accessibility to other nurses Srongly Disagree 0% Strongly Agree 0% N/A 8% 35% 30% 25% 20% 15% 10% 30.3% 0.3 Staff Turnover 25.1% 0.25 14.7% 13.8% 13.8% 0.15 0.14 0.14 Disagree 17% Neutral 21% Agree 54% 5% 0% Old Unit Heart Hospital (2007) Heart Hospital (2008) New Heart Hospital (2015) Children's Tower (2015) Current: 16.5% all units The facility design supports the staffing model of the unit. (i.e. the design of the space supports the way we work.) 34

Survey Results: Nursing Efficiency Supply System The cabinets in patient rooms are used to stock supplies, but we have to throw out any supplies that don t get used. Having one room bigger than the other is inconvenient as they both aren t stocked with the same things. Supply rooms are different sizes and are not adequately stocked. Srongly Disagree 4% N/A Disagree 8% 4% Strongly Agree 9% Neutral 17% Agree 58% The distribution of medical supply rooms supports my ability to provide patient care. 35

Operational Alignment Supply Room Gemba Walk 36

Conclusions: Design take-aways: The Triple Corridor plan does contribute to a quiet patient room Other factors and behaviors also significant to reducing noise Distributed Nursing Stations and supply rooms reduce nurse travel time significantly freeing up nursing time. However, impact on HCHAPS staff responsiveness was ambiguous. 37

Conclusions - continued Hospital Management/Operational take-aways POEs can surface operational performance/adaptation issues Consistent training for Change Management is critical to design performance Solid evidence can improve judgements for investment premiums Measurable value vs. alternative opportunity 38

Conclusions -- continued Process related take-aways POE methods/findings are effective way to understanding design and operational performance And, serve as basis for design standards Comparison with 07, 08 studies revealed a novelty effect -- newness boosted positive response Time separated evaluations may reveal true findings Building a body of evidence requires scientific rigor 39

Q&A Presenters: Jeff Johnston, President, Mercy Hospital, St Louis John Reeve AIA, Principal, Christner Architects 40

Survey results Assessment of Triple Corridor It s much quieter, however, families often congregate in the patient corridors and have to be asked to move to the patient rooms It is definitely quieter for both patients and nurses. Center isle reduces traffic in front of patient rooms The triple corridor is great for people who are familiar with the unit, but can be confusing for visitors Srongly Disagree 21% N/A 8% Strongly Agree 8% Agree 4% Neutral 21% Disagree 21% N/A 8% Strongly Agree 12% N/A 17% Srongly Disagree 12% Agree 29% Disagree 38% Neutral 13% Agree 46% Disagree 13% Neutral 29% The triple corridor makes it difficult to get from one side of the unit to the other. The triple corridor layout is confusing for visitors. The triple corridor cuts down on my travel time during the day. 41