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Understanding Healthcare Design Designing Spaces that Work
Jesus Cepero, MSN, MPA, RN, NEA- BCVice President, Critical Care and Heart Institute
Childrens National Medical Center, Washington, D.C.
Rose Szeles, MS, RN, NE-BCManager Professional Nursing Practice
Childrens 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 toget it right!
Objectives
Identify phases of healthcare design.
Describe the nurses role in phases ofhealthcare design.
Use the evidence of healthcare design inpromoting the environment of healing.
Examine the impact of the environment on
patient safety.
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Objectives cont.
Relate the impact of the environmentaldesign on staff and patient satisfaction.
Examine the influence of healthcare designon patient care.
Examine current trends in healthcaredesign.
18th century facilities called almshouse,
Mainly served indigent, orphanages, sickwho had no place to go
Benjamin Franklin co-found PennsylvaniaHospital in 1752, UPenn now the NationsFirst Hospital to replace almshouse to
serve the poor and needy
History of Hospitals
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Took another 100 years to develop
Childrens of Philadelphia now CHOP 1855
Boston Children's opened in 1869
DC Childrens now Childrens NationalMedical Center opened 1874
Childrens Hospitals
DC Childrens Opens 1874Now ChildrensNational MedicalCenter
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Hospitals moved away from medicalexperimentation, added clinical techniquesand medical training as well as safelytreating patients in high volumes.
It was not until the late 19th Century thathospitals became part of the community anda source of civic pride
Civil War
Second largest private-sector employer inthe US and contributes nearly 2 Trillion tothe economy
Largest employer in the District ofColumbia
Teaching site for all Medical and Allied
Health professions.
Hospitals Today
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It is estimated that $100 billion in inflation-adjusted dollars has been spent on newconstruction in the past 5 years and $250billion will be spent in the next 10 years.
Clancy, 2008
Financial Impact of HealthcareDesign
The Institute of Medicine (IOM), Agency forHealthcare Research and Quality (AHRQ) andthe Joint Commission have all indicated that thework environment impacts not only patient andnurse satisfaction but also patient outcomes.
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Patient room design is extremely important becauseit is duplicated numerous times throughout thehospital environment.
Decisions made about hospital designtoday will have an impact on how care isdelivered for decades.
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Nurses are in a unique position to impactdesign decisions as:
Advocates for patients and families
Professionals who have an understanding ofprocesses that support patient care which areinfluenced by the built environment
Nurses Role
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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
Nurses as Leaders
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Evidence Based Principles
Address high level priorities i.e. IC,Emergency preparedness, noise etc
Include Clinicians
Design Flexibility
Incorporate green principles
Address practice implications ***
Principles of Healthcare 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
Phases of HC Design
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Space plans to meet the programmaticneeds and allocation of square footage toeach space
200 Sq feet MS
250-350 Sq Feet CC
300-600 Sq Feet OR
15-20% allocation for support space - low
Space Programming
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Flexible to accommodate different ratios
Adaptable to accommodate levels of acuity
Multiple diagnosis / ages
Growth surge capacity flex up / down
Design
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Is difficult task
To large walking distance burn out
To small isolates staff, inefficient
Trend 32 bed units cost and spaceefficient
Largest recommended 54 beds
Determining Optimal Number
Centralized
Decentralized
Family support areas in room?
Visitor amenities coffee bar?
Care Delivery Models
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Targeted census productivity targets at atarget of 80% occupancy determines the # ofbeds needed:
i.e. a unit with a targeted occupancy of 22patients a day at 80% occupancy would need28 beds. (28X 80% = 22.4)
Efficiency
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 at10-20% of total sq feet
Cost to Construction
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Floor plans for each clinical area prepared
Not final
Conceptual
CON in most regions at this point.
Schematic Design
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Room detail and surfaces in each room isdetermined
Design Development
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MOVE PLAN
Begins months before occupancy
Multidisciplinary
Sequencing of patients
Process for the move
Ancillary support
Tracking system
Occupancy Planning
Most difficult task
IT
Equipment
Floor plan facilities
Rooms
Decentralized stations
Med rooms
Education
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Technology
Phones
Computers
Tracker devices
Getwell Network
White Boards
Monitor alarms - tracking responses
EMR impact
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Healing Environment
Safety
Satisfaction
How Space Impacts Care
The notion that the physical environment hasthe potential to impact healing is not new itis as old as antiquity. Hippocrates referred tothe environment as the fourth factor followingdisease, patient and physician as contributingto healing.
J.M. Currie The Fourth Factor: A
Historical Perspective onArchitecture and Medicine
Healing Environment
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Natural light
Airiness
Cleanliness
Order
Quietness
Proper Nutrition
Florence Nightingale
Emerged from the unpleasant hospitalexperience of Angelica Thieriot in the 1970s
She founded the non-profit organizationcalled Planetree to transform healthcareexperiences
Planetree
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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 holisticbeing with integration of mind, body andspirit
J. Stichler Healing by Design 2008
Planetree
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Exposure to nature has been demonstrated tohave calming restorative effect on pediatricpatients and their families
Views or images of nature and natural lightare associated with reduced stress andincrease pain tolerance
Exposure to view of nature positively affectscaregivers, on a daily basis it can improve
alertness and improve focus
(Debajyoti, Harvey, Barach 2008)
Access to Nature
Noise
Lighting
Infection
Single-Patient Rooms
Distance and Space
Safety
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Sound has many different manifestationsfrom disturbing and stressful to soothing andcalming
Speech is sound
Noise is unwanted sound
Hospitals are generally extremely noisy
Sound
World Health Organization (WHO) hasdefined values for background hospitalnoise in patient rooms Daytime 35 dB
Nighttime 30 dB
Busch-Vishniac (2005) reviewed 35published studies over 45 years Not one
reported noise levels the were withinWHO values
A. Joseph, R. Ulrich www.healthdesign.org
Hospital Noise
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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
Hospital Noise
Exposure to excessive noise in NICUs impactsshort-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
Noise and Patients
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Increased stress and annoyance
Interferes with ability to work effectively
Evidence suggests that reduced noise levelsresult in more effective recall andcommunication of information and reductionin perceived work demand and pressure
Benjamin, DeWitty, Scott 2008
Noise and Staff
Effective methods to reduce noise
Sound absorbing ceiling tiles and flooring
Single patient rooms
Staff and family education related to effects ofnoise
Noise
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Patients exposed to brighter natural sunlighttook 22% less medication for pain per hour
Sufficient lighting for caregivers whencompleting complex tasks such as preparingmedications reduces errors
There is increased need for illumination withincreased age
Average age of nurse in the US is 45.2 years
Lighting
Access to Natural Light andNature
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The Joint Commission stated in its 2008HealthCare at the Crossroads: Guiding Principles forthe Development of the Hospital of the Futurethat single-patient rooms may have the singlemost important impact on patient safety .Single rooms help protect patients health.
Single Patient Rooms
Can reduce the number of transfers andhandoffs
Improve patient flow
85 beds in single patient rooms function as thesame bed capacity as 100 multi-patient bedrooms (Detsky, Etchells 2008)
Benefits of Single Patient RoomsCurrent Trends
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Infection control Decrease spread of infectious agents between
patients sharing a room
Increase visual cue for caregivers to wash handsprior and after contact with patients
Easier to decontaminate empty single patientroom than shared patient room
Benefits of Single Patient Rooms
Quieter
Privacy
Decreased interruptions promotes rest andrecovery
Supports family participation in care
Facilitates private consultations with care
providers
Benefits of Single Patient Rooms
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Decentralized work stations and supply andmedication rooms facilitate nurses being closerto patients and increase in direct-care activities
Distance and SpaceCurrent Trends
Caution: Caring for patients is a team activityrequiring official and unofficial collaborationwith other nurses and other members of themultidisciplinary team
Teamwork and communication are critical toproviding safe patient care
Decentralized work stations must be combined
with flexible spaces for interactive teamcollaboration and social interaction
Teamwork and
Collaboration
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Team/Collaborative Space
Healthcare environment must be designed forthe care giving processes
Direct correlation between staff performanceand patient safety
Poorly designed environments force work-around
70% of hospital preventable errors orpotential errors are the result of process errors
Influence of Design on Patient
Care
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No involvement of nurses or other healthprofessionals in design
Noted Defects ED and ICU rooms too small
Resuscitation room in ED does not allow staff access tohead of patient
Patients in Mental Health Unit have access to roof andcourtyard leading to 20-metre drop
Pediatric patients have access to roof with 3 story drop Maternity assessment room doorway too narrow for
stretchers
January 2008 Disastrous Opening ofBathurst Hospital in New South Wales
Rooms and units organized in an identicalmanner
Standardization fosters force functioningof routine tasks by designing theenvironment in such a way that guidescaregiver processes in the most efficient andsafe manner
Supports unit adaptability to adjust tochange in volumes or acuity
StandardizationCurrent Trends
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Same-Hand DesignBeds - oriented againstthe same wall in everyroomRooms - identical so usebecomes intuitive therefore saferCan be more expensive tobuild because each roomrequires its own plumbingand medical gas drops
Mirror-Reverse Design
Beds oriented againstopposite walls
Headwall can bestandardized to decreasevariation
Standardization
No conclusive evidence that supports same-handed rooms are safer
Suggestions
Reduce the number of rooms types to decreasevariation
Standardize same-handed rooms where chances ofcritical events are high (ED, ICU)
Standardize placement of medical gases inheadwall so that use becomes more intuitive
Standardization
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Design of space impacts the quality of nurseswork life, job satisfaction, stress andproductivity
Nurses job satisfaction has been shown to be amore important predictor for patient
satisfaction than nursing skill(Berry, Parish 2008)
Satisfaction
Environments that support active involvementby families in the care process demonstratehigher levels of satisfaction among patientsand families
Satisfaction
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LEED Leadership in Energy andEnvironmental Design
Certification is done by US Green BuildingCouncil
LEED and GreenCurrent Trends
Establish common standard of measure for agreen building
Promote integrated whole building designpractices
Stimulate green competition
Raise consumer awareness
Transform building market
(Healthcare Informatics, 2008)
Creation of LEED to:
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2008 celebrated its official designation as theworlds first LEED Platinum hospital
Dell Childrens Medical CenterAustin, Texas
Dell Childrens Medical Center
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Hospitals are major contributors to toxic waste
Intravenous bags and tubings PVC whenincinerated releases dioxin and other toxicsubstances
Wastes from body fluids, toxic cleaningsupplies and medication waste move intowater supply
Going Green
Recycle to reduceenvironmental impact
Reuse cleanablematerials
Renew usesustainable buildingmaterials
Refuse to purchase
supplies that are notbiodegradable
Reduce use of fossilfuels (promote carpools,public transportation,high efficiency bulbs,solar or wind energy tosupplement energysupplies, rainwatercollection)
The Rs of going Green
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Cost savings if able to reduce energydemands
Water consumption through rainwater storageand drought resistant landscaping can reduceconsumption by 30%
Natural lighting reduces energy use
Advantages of Going Green
Helps hospitals align their actions with theirmission to improve the health of thecommunity they serve
Going Green
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Conclusion
New Design
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