Safety by Design Initiatives at AHRQ

Agency for Healthcare Research and QualityAgency for Healthcare Research and QualityAdvancing Excellence in Health CareAdvancing Excellence in Health Care • • www.ahrq.govwww.ahrq.gov

Safety by DesignSafety by DesignInitiatives at Initiatives at AHRQAHRQ

Kerm HenriksenKerm Henriksen

Sandi IsaacsonSandi Isaacson

Catherine HinzCatherine Hinz

Advancing Advancing Excellence in Excellence in Health CareHealth Care Three ObjectivesThree Objectives

Describe AHRQ’s Describe AHRQ’s involvement in safety by involvement in safety by design design

Provide some examples of Provide some examples of safety by design in the safety by design in the hospital environmenthospital environment

Show DVD on how design of Show DVD on how design of the hospital environment can the hospital environment can have a a transforming effecthave a a transforming effect

Evelina Children’s Hospital South London

Advancing Advancing Excellence in Excellence in Health CareHealth Care

Crossing the Quality Chasm:Crossing the Quality Chasm:Designing in Safety and QualityDesigning in Safety and Quality

Current $250 billion building Current $250 billion building boom in US in new hospital boom in US in new hospital constructionconstruction

Design has a direct impact on Design has a direct impact on patients, families & providerspatients, families & providers

Emerging evidence base from Emerging evidence base from past two decades affirms that past two decades affirms that safety & quality can be safety & quality can be designed into construction of designed into construction of new facilities.new facilities.

Ulrich et al. 2004Ulrich et al. 2004

First we shape our buildings, and then First we shape our buildings, and then

our buildings shape us. - our buildings shape us. - Winston ChurchillWinston Churchill


AHRQ’s Involvement in AHRQ’s Involvement in Safety by DesignSafety by Design

Informal cross-center Informal cross-center workgroupworkgroup

Georgia Tech Small Georgia Tech Small Conference GrantConference Grant

HIT grant to St. Joseph’s HIT grant to St. Joseph’s Community Hospital Community Hospital

Mistake-Proofing with Dr. Mistake-Proofing with Dr. John GroutJohn Grout

QSHC Safety by Design QSHC Safety by Design SupplementSupplement

Blueprint for Change Blueprint for Change Podcast with Dr. ClancyPodcast with Dr. Clancy

AHRQ Presentation – Role AHRQ Presentation – Role of Physical Environmentof Physical Environment

Transforming Hospitals Transforming Hospitals by Design DVD by Design DVD

Articles Articles in press in press


Quality & Safety in Health Care: Quality & Safety in Health Care: Safety by DesignSafety by Design

Rather than continuing to try to measure the width and depth of the quality chasm . . . . . how does one actually begin to close the quality chasm? One way to think about the problem is as a design challenge rather than as a quality improvement challenge. It is time to move from reactive measurement to a more proactive use of proven design methods, and to involve a number of professions outside health care so that we can design out system failure and design in quality of care.

Battles, Dec. 2006


Quality & Safety in Health Care: Quality & Safety in Health Care: Safety by DesignSafety by Design

Supplement includes articles on design of:

• High reliability organizations (HROs) • Clinical microsystems• Training initiatives • Clinical work processes• Healthcare worker performance • System latent conditions• Healthcare software usability

Advancing Advancing Excellence in Excellence in Health CareHealth Care No Environment is NeutralNo Environment is Neutral

The design of facilities, The design of facilities, work processes, technology,work processes, technology,and organizations impact oneand organizations impact oneanother as well as providersanother as well as providerspatients, and their families.patients, and their families.

Either positively or negatively,Either positively or negatively,the design will exert itsthe design will exert itsimpact.impact.

Advancing Advancing Excellence in Excellence in Health CareHealth Care Evidence-Based Design (EBD)Evidence-Based Design (EBD)

In parallel with evidence-based medicine, In parallel with evidence-based medicine, EBD uses the best available information from EBD uses the best available information from credible researchcredible research

Utilizes findings & expertise from architecture, Utilizes findings & expertise from architecture, health design, clinical work processes, HIT, health design, clinical work processes, HIT, human factors & ergonomics, industrial & human factors & ergonomics, industrial & system engineering, environmental system engineering, environmental psychology & organizational theorypsychology & organizational theory

Employs function & task analyses, failure Employs function & task analyses, failure mode & effects analyses, learning labs for mode & effects analyses, learning labs for design teams, mock-ups, modeling, design teams, mock-ups, modeling, simulations, iterative testing & evaluation, simulations, iterative testing & evaluation, usability testing, and operational try-outs in usability testing, and operational try-outs in addition to experimental designsaddition to experimental designs

Advancing Advancing Excellence in Excellence in Health CareHealth Care Evidence Based Design (EBD)Evidence Based Design (EBD)

Build Single Patient RoomsBuild Single Patient Rooms Reduce NoiseReduce Noise Incorporate NatureIncorporate Nature Improve Air QualityImprove Air Quality Encourage Hand Hygiene Encourage Hand Hygiene Improve Way-finding Improve Way-finding Reduce Walking DistanceReduce Walking Distance


Small Conference Grant Small Conference Grant to Georgia Techto Georgia Tech

Healthcare Environments Research Summit Healthcare Environments Research Summit 20062006

http://hcdesign.coa.gatech.eduhttp://hcdesign.coa.gatech.edu Summit focused on:Summit focused on:1. High priority research directions1. High priority research directions2. Research to application pipelines 2. Research to application pipelines

3. Call to action – near & mid-term 3. Call to action – near & mid-term goalsgoals


Design Principles at St. Joseph’s Design Principles at St. Joseph’s Community Hospital in West Bend, WICommunity Hospital in West Bend, WI

Patient to Staff VisibilityPatient to Staff Visibility StandardizationStandardization New TechnologyNew Technology Noise ReductionNoise Reduction Quick Access to Quick Access to

InformationInformation

Involve Patients with CareInvolve Patients with Care Scalability & AdaptabilityScalability & Adaptability Minimize FatigueMinimize Fatigue Design for Precarious Design for Precarious

EventsEvents Minimize Patient Minimize Patient

Transfers/HandoffsTransfers/Handoffs


Evidence Based Design Evidence Based Design DVDDVD

Transforming Hospitals: Three Case Studies

DVD examines three hospitals that have incorporated evidence-based design in renovations or initial

construction

Release Date: October 2007

Advancing Advancing Excellence in Excellence in Health CareHealth Care Physical EnvironmentPhysical Environment

Facility design & layoutFacility design & layout Lighting Lighting Noise Noise Temperature & humidityTemperature & humidity VibrationVibration Air flowAir flow Contamination & pollutants Contamination & pollutants

Workplace hazardsWorkplace hazards Safety featuresSafety features Security featuresSecurity features Signage & way-findingSignage & way-finding Workstation ergonomicsWorkstation ergonomics Special user group requirements Special user group requirements

& equipment & equipment

In adopting a systems perspective, research needs to examine how the physical environment interacts with people, work processes, tools/technology, and organizations to realize improved processes & outcomes.


Acuity Adaptable RoomsAcuity Adaptable RoomsBringing different levels of acute care to the patient

Operationalizes concept of patient-Operationalizes concept of patient-centerednesscenteredness

ICU capable headwallICU capable headwall Sink for hand hygieneSink for hand hygiene Adjacent nurse work stationAdjacent nurse work station LCD Window ObservationLCD Window Observation Flat Screen MonitoringFlat Screen Monitoring Family AccommodationFamily Accommodation Patient EducationPatient Education

Three-year post-intervention data show Three-year post-intervention data show considerable reduction in transfers (90%), medical considerable reduction in transfers (90%), medical errors (70%), and number of falls errors (70%), and number of falls Hendrich, Fay, Sorrells, 2004


Use of Natural & Use of Natural & Full Spectrum LightingFull Spectrum Lighting

Helps reduce depressionHelps reduce depression Restores disrupted circadian rhythmsRestores disrupted circadian rhythms Less perceived stress, pain, use of analgesic medicationLess perceived stress, pain, use of analgesic medication Shorter length of stay Shorter length of stay

Ulrich, Quan, Zimring, Joseph & Choundhary, 2004

Advancing Advancing Excellence in Excellence in Health CareHealth Care Reduce Noise LevelsReduce Noise Levels

Install sound-absorbing ceiling tiles/wall panelsInstall sound-absorbing ceiling tiles/wall panels Treat hallways to reduce equipment soundsTreat hallways to reduce equipment sounds Decentralize nursing stationsDecentralize nursing stations Eliminate overhead paging systemsEliminate overhead paging systems Evaluate alarm appropriatenessEvaluate alarm appropriateness Mask noxious sounds with pleasant soundsMask noxious sounds with pleasant sounds Establish quiet zones & interrupt-free zonesEstablish quiet zones & interrupt-free zones Build single-patient roomsBuild single-patient rooms


WayfindingWayfinding“aah . . .which way do I go . . . . . I’ll just sit here.”

Are entrances and exits obvious?Are entrances and exits obvious? Are directional signs used appropriately at Are directional signs used appropriately at

intersections?intersections? Is the visual environment free of clutter?Is the visual environment free of clutter? Do icons clearly convey intended Do icons clearly convey intended

meaning?meaning? Do “you are here” maps also show where Do “you are here” maps also show where

users want to go?users want to go? Are floor and room number schemes easy Are floor and room number schemes easy

to understand?to understand? Is terminology used on signage plain and Is terminology used on signage plain and

simple?simple?

Advancing Advancing Excellence in Excellence in Health CareHealth Care Expected Benefits Using EBDExpected Benefits Using EBD

Safer environment for patients & Safer environment for patients & providersproviders

Improved work processes & flowImproved work processes & flow Greater standardization for efficiencyGreater standardization for efficiency Electronic access to medical recordsElectronic access to medical records Improved hand hygiene Improved hand hygiene Single bed rooms to reduce HAISingle bed rooms to reduce HAI Better air filtration systemsBetter air filtration systems Mistake proofing for devices Mistake proofing for devices Improved patient lifts & handlingImproved patient lifts & handling

Kinder working conditionsKinder working conditions Improved transitions of care Improved transitions of care Prevention of falls Prevention of falls Shorter wait times Shorter wait times Adjustable lightingAdjustable lighting Noise reductionNoise reduction Improved signage & way-findingImproved signage & way-finding Shorter healing & recovery timeShorter healing & recovery time Better family/ visitor accommodationBetter family/ visitor accommodation


A New Way of Thinking forA New Way of Thinking forHealth Services ResearchersHealth Services Researchers

Focuses on quality & safety Focuses on quality & safety before hospital is built rather before hospital is built rather than later as an after-than later as an after-thought; eliminates adoption thought; eliminates adoption problemproblem

Achieves maximum leverage Achieves maximum leverage by informing capitol budget by informing capitol budget decision- making rather than decision- making rather than limited operating budgetslimited operating budgets

Reaps daily savings in Reaps daily savings in terms of safety, terms of safety, effectiveness & efficiency effectiveness & efficiency that accrue for decades & that accrue for decades & decadesdecades

Hospital building boom is Hospital building boom is on national radar screen; on national radar screen; now is the time to be now is the time to be involved.involved.


Evidence Based Design Evidence Based Design SourcesSources

1. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity (Center for Health Design)

2. Improving Healthcare with Better Building Design (Center for Health Design)3. Planning, Design, and Construction of Health Care Facilities (Joint

Commission Resources)4. Guidelines for Design and Construction of Hospital and Healthcare Facilities

(The American Institute for Architects)5. Enhancing the Traditional Hospital Design Process: A Focus on Patient

Safety (Joint Commission Journal on Quality and Safety) Play video

Safety by Design Initiatives at AHRQ

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