Nuture by Steelcase 2012 Healthcare Design Competition

Communication In a Technology-first Environment: How Collaboration is Vital to Shift Change

A four-person team submission to the

Nurture by Steelcase 2012 Collegiate Healthcare Design Competition

Shifting Gears in Healthcare

an urban renovation site at University of Kentucky Albert B. Chandler Hospital in Lexington, KY

With the advancement of technology in the healthcare setting, staff communication is suffering. While technology has an ability to provide a previously unknown sense of independence in the access and use of information, the once liberating freedom can lead to isolation. This disconnect not only exists within the environment, but between the people who share it.

In a work environment such as healthcare, where collaboration and communication are essential, interaction with co-workers has implications beyond mere job satisfaction. Technology is greatly changing how health employees work, and is also changing how they interact. Now as the work environment begins to react and engage with the technology to support and encourage its use, it must also focus on fostering staff engagement and ensuring face-to-face interaction.

In exploring how to better improve communication between staff, it was discovered that shift change is key in how patient information is transferred and is a significant link in process of patient safety and care.

In preparing for this competition entry, we have developed a hypothesis and three design objectives that illustrate our research findings and our design intent.

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HYPOTHESISResearch shows that shift change is a crucial period for patient safety and quality of care as it relies heavily on accurate and effective message transmission, both in the forms of hard technology and informal dialogue. Therefore, it is vital to provide a collaborative environment that facilitates clear communication and access to information in order to provide a healthy and safe environment for both staff and patient.

Design ObjectivesWorking toward the end environmental goal: to ensure high quality of care and patient safety.

Staff Collaboration

Effective Message Transmission/Communication

Improved Work Environment

- Standing height working surfaces

- Large, sit-down work surfaces

- Alcove huddle spaces outside rooms

- Standing work stations

- Acoustic separation from Nurses Station

- Smartboard/Message Boards

- Simulated skylights

- Task-lighting

- Acoustic ceilings

Design Implementation

Tower 10012 ICU, 20 Stroke Beds

Center Core Support

Center Core Support

ProgressiveICU

ICU

Acute

Stroke

Stroke

Stroke

ICU

ICU

ICU

ICU

Team Station

Cent

ral C

orrid

or

Tower 20012 ICU, 6 Progressive, 14 Acute Beds

Floor 6

Art Public Elevators Sta� Elevators

SupportServices

Stairs

Acute

Acute

WaitingArea

WaitingArea

Team Station

Service Elevators

ICUTeam

Station

From the New Pavilion Guide for the UK Albert B. Chandler HospitalProduced by UK HealthCare, Lexington, KY.

Team Station

The SiteUK Albert B. Chandler Hospital, Lexington, KY

Existing Floorplan

Highlighted areas are spaces that have been altered with the design proposal.

Proposed Floorplan Changes

Huddle Spaces

Enclosed Area in Nurse Station

Enclosed Space for Shift Change

Shift Change Room

Floor 6

Art Public Elevators Sta� Elevators StairsService Elevators


The goal when designing the shift change room was to create a quiet space for nurses to handover the necessary information to the incoming nurses. Interruptions and distractions are common issues occurring during this process. Creating a separate room for shift change would help eliminate problems and allow for more effective transfer of information to improve the patients’ safety. With glass dividing walls, there are views into and out of the space.

IMPROVED ENVIRONMENTAcoustic Ceiling

COMMUNICATIONSmart Board/Message Board

COLLABORATIONLarge Work Surface

COMMUNICATION Separation from Nurse Station

COLLABORATIONMulti-level Seating

“Environmental interventions that have proven especially effective for reducing noise and improving acoustics in hospital settings include: installing high-performance sound absorbing ceiling tiles...” 11

“A combination of open-counter work spaces with adjacent small work rooms with doors is helpful in having the flexibility for staff to minimize interruptions as required by the tasks...Within the open-counter work area, a certain portion could be enclosed to reduce disruptions from noise and reduce interruptions, yet allowing visual connection with the hallways” 2

Inside the shift change room, nurses prepare for their shift with personal notes and/or an annotated patient care summary, and “[obtain...] the latest patient information from the large whiteboards which had been updated by the nurses working in the previous shift.”

During charge nurse handover, nurses were observed “[preparing] some.form of personal notes, either on a separate sheet of paper and/or as annotations on the printed patient care summary. ... [T]he majority (83%) wrote down the notes from the previous shift, either from the large whiteboard inside the shift change room or from the verbal report by the outgoing nurse.”

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Nurses assemble and disassemble information about the patients. “Shift reports posted on the whiteboards usually contain shift-specific activities and patient information that the outgoing nurse has performed and gathered. “10

Nurses’ Station

Floor 6



When designing the layout of the nurses’ station, an open layout with standing height workspace was desirable. Plenty of counter space and computers are easily accessed without having to sit down inside the nurses’ station. From this space the views into the patient rooms as well shift change room are preserved. Task lighting was incorporated to better serve both paper tasks and computer tasks.

IMPROVED ENVIRONMENTTask Lighting


COMMUNICATIONSmart Board/Message Board

IMPROVED ENVIRONMENTSimulated Skylights


COMMUNICATIONStanding Work Station

“Research has revealed that the indoor environment has the biggest effect on productivity in relation to job stress and job dissatisfaction”

“Computer-based tasks benefit from significantly lower light levels, with carefully controlled direct and reflected glare, while the remaining paper-based tasks still demand high levels of light for individual tasks.”

User satisfaction for paper based tasks was elevated with higher illuminance levels beyond the current minimum of 500lx. However a VDT computer screen monitor the minimum light level should be 100lx and the maximum at 350lx. A higher light level than 350 is when dissatisfaction begins and the computer monitor needs to be lit at a higher level as well. Because hospital environments require both paper based and computer based tasks, there should be a lower ambient light and separate task lighting for paper based work.

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Huddle Space

Floor 6


From the New Pavilion Guide for the UK Albert B. Chandler HospitalProduced by UK HealthCare, Lexington, KY.The goal when designing the huddle

space was to create a work area that both nurses and residents have easy access to while in the hallway. Since much dialog is exchanged between staff in the hallway, the huddle space provides a new location where a quick exchange of information and impromptu meetings can occur.

COMMUNICATIONStanding Work Station

“Curbside is where impromptu meetings take place-quick consultations, chart reviews, etc. ...and is best served by a standing-height work surface that two or more can gather around easily. This type of space is even more important when groups work and roam the floor, such as during physician rounds.”

“Informal interactions are often undervalued, yet studies in office and educational environments show that these interactions play an important role in successful collaborative relations.

COLLABORATIONHuddle Space


COLLABORATIONStanding height Work Surface

IMPROVED ENVIRONMENTViews of Nature Artwork

“Investigators have reported consistently that stress-reducing or restorative benefits of viewing nature are manifested as a constellation of positive emotional, psychological, and physiological changes. Positive feelings such as pleasantness and calm increase, while anxiety, anger or other native emotions diminish,”

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During resident’s rounds and nurse shift changes, the hallway is a critical location for dialog.. “[M]edical interns and physicians spend a significant part of their time in the hallway... [and] ... choose [it] to discuss the health condition of a patient with colleagues or relatives. Thus, the hallway is used as an ‘availability space’ where many discussions and information exchanges take place. These opportunistic interactions are used among other things to hand physicians a form to sign, ask about the status of a patient, or discuss a clinical decision.” 812

ICU Nurses’ Station

Floor 6



While designing the layout of the nurses’ station in the ICU, an open furniture layout with standing height workspace was desirable. Plenty of counter space and computers are easily accessed without having to sit down inside the nurses’ station. Views into the patient rooms and also into the quiet pods were preserved throughout the design.

“Step-in [spaces are] for more involved work such as charting, dictation, or going over a treatment plan. Seated-height tools are beneficial here, possibly with some medium-height panels to provide some acoustic privacy. “

“Technology can enable real-time updating of information at satellite nurses’ stations, reducing cognitive load and enhancing work processes.”


IMPROVED ENVIRONMENTSimulated Skylights

COLLABORATIONStanding-height Work Surface

COMMUNICATION Separation from nurse station


“[N]urses function more effectively in an environment with minimal artificial lighting and in an environment that facilitates the use of natural daylight.” The product specified for this space would emmulate natural daylightin an area without access to direct exterior views or light.

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“To support the social ecology and work processes while allowing for maximum control and flexibility, it is important to incorporate different types of workstations in support of different work activities, (i.e., sitting versus standing, groups versus individuals, private versus shared). “

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Quiet Pod

Floor 6



The idea for adding the quiet pod was to create a separate space where nurses can go and fully immerse themselves in the work with very little distractions.

“[N]urses preferred unit layout in which they have a visual link to the patients, yet have audio privacy. Small alcoves within the nursing station were found to be beneficial, as nurses can communicate with other staff members regarding patients while still maintaining low noise levels within the nursing unit. Nursing units closed off with Plexiglas were also found to be beneficial due to high patient visibility with low levels of noise.”


COMMUNICATION Separation from nurse station

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“Immersive space allows for concentration and privacy for planned meetings or work where participants not only need to fully immerse themselves in the work, but also have access to tools like computers, whiteboards, or other information displays.” 1

Our Evidence-Based Design Process

Define EBD Goals +

Objectives

Find Sources for Relevant

Evidence

Critically Interpret RelevantEvidence

Create +Innovate

EBDConcepts

Develop a

Hypothesis

CollectBaseline

Performance Measures

Monitor Implementation of Construction

+ Design

Measure Post Occupancy

Performance Results

While this was our first time participating in the EBD process and our experience was limited, we relished the opportunity to dive into research and then apply it directly to a design project.

After our own observation and experiences with technology in the healthcare setting, we set our primary goal on fostering staff engagement and face-to-face interaction.

The focus of our research was on nurse-physician relationships, the clinical environment including stress and satisfaction levels, and communication and collaboration issues.

While research regarding poor communication levels due to technology supported our initial suspicions, it was nurse and physician surveys which revealed how essential shift change is in the patient care process.

As we investigated shift change, its role, and process within the routine of the hospital, the development of our design objectives and design intent began to form.

Our three design objectives drove the generation of our hypothesis and we were able to clearly identify an environmental problem, and suggest a solution through design.

While outside our scope and ability, we feel that patient incident reports, staff satisfaction surveys and behavioral mapping techniques would be suitable methods for this stage.

At this stage, careful attention and observation would be paid to how well the established design objectives and standards were being carried out.

Eight-Step EBD Process

Further Research

∙ Monitor incident reports

∙ Evaluate efficiency of design comparing current and

former shift change time duration

∙ Survey staff about environmental perceptions and

satisfaction

Staff Collaboration

For the final stage in the EBD process,, we would focus on research techniques that could be easily compared with results from initial testing, hopefully resulting in evidence that shows environments designed for collaboration might improve patient care and safety. This team would also like to propose other research on the same topic, specifically on staff satisfaction, as well as patient satisfaction as a result of the change in design. Below is listing of possible research techniques, broken down by each of our design objectives.


∙ Annual Performance Reviews regarding efficiency and

group work

∙ Compare utilization of previous and current work

surfaces

Effective Message Transmission/Communication


∙ Survey staff about environmental changes throughout

the work stations

∙ Observe attitudes during shift changes to ensure

positive improvement

∙ Test acoustic and lighting levels according to ASHRAE

standards

Improved Work Environment

By using the steps of the Evidence Based Design process, we found a need to improve the communication among staff, specifically during the shift-change process between nurses. Interruptions and distractions are a concern during the shift change process, making it last much longer than it should. By adding an enclosed space used for the nurses’ shift change, it makes the process quicker and improves the patient safety through better hand-off techniques.

The other major issue addressed was dialogue which occurs when healthcare professionals move between patient rooms, the hallway is a critical space for the transfer of a patient’s information. ‘Huddle spaces ‘ were created in the hallway so that nurses, doctors, and residents can quickly access information as a group.

The addition of the shift change room, huddle spaces, and minor environmental modifications significantly improves communication among health care workers and improves the safety of patients.

Summary

Bromberg, J. (2006). Planning and designing highly functional nurses’ stations. Healthcare Design, 11, 80-88.

Chaudhury, Habib, Atiya Mahmood, and Maria Valente. “The Effect of Environmental Design on Reducing Nursing Errors and Increasing Efficiency in Acure Care Setting: A Review and Analysis of the Literature.” Sage Publications 41.6 (2009): 80-88. Sage Journals Environment & Behavior. Web. 10 May 2012.

Choi, Joon-Ho, Vivian Loftness, and Azizan Aziz. “Post-occupancy evaluation of 20 office buildings as basis for future IEQ standards and guidelines.” Energy and Buildings 46 (2012): 167-175.

Dracup, Kathleen, and Peter E. Morris. “Passing the Torch: The Challenge of Handoffs.” American Journal of Critical care 17 (2008): 95- 97. American Journal of Critical Care. Web. 24 Apr. 2012.

Holden, Richard J.. “Physicians’ Beliefs About Using EMR and CPOE: In Pursuit of a Contextualized Understanding of Health IT Use Behavior.” International Journal of Medical Informatics 79 (2010): 1-16.

Holden, Richard J. “Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety.” Cognition, Technology & Work 13.1 (2011): 1-30. Print.

Knaus, W., Draper, E.,Wagner, D., Zimmerman, J. (1986). An Evaluation of Outcome from Intensive Care in Major Medical Centers. Annals of Internal Medicine, 104, 414-416.

Mejia, David, Alberto Moran, Jesus Favela, Monica Tentori, Antoine Markarian, and Luis Castro. “On The Move Collaborative Environments: Augmenting Face To Face Informal Collaboration in Hospitals.” e-Service Journal 6.1 (2007): 98-124.

Roelofsen, Paul. “The Impact of Office Environments on Employee Performance:The Design of the Workplace as a Strategy for Productivity Enhancement.” Journal of Facilities Management 1.3 (2002): 247-264.

Tang, Charlotte, and Sheelagh Carpendale. “An Observational Study on Information Flow during Nurses’ Shift Change.” CHI ‘07 Proceedings of the SIGCHI conference on Human factors in computing systems Medical (2007): 219-228. ACM Digital Library. Web. 2 Apr. 2012.

Ulrich, Roger, Xiaobo Quan, Craig Zimring, Anjali Joseph, and Ruchi Choudhary. “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity.” The Center for Health Design 1 (2004): 1-69. Print.

Ulrich, R. S., Zimring, C., Zhu, X., Dubose, J., Choi, Y., Quan, X., Joseph, A. (2008). A Review of the research literature on evidence-based healthcare design. Health Environments Research & Design Journal, 1, 61-125.

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Nuture by Steelcase 2012 Healthcare Design Competition

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Transcript of Nuture by Steelcase 2012 Healthcare Design Competition