Part 2 - Evidence Based Design - American College of Healthcare ...

Emerging Trends & Successful Strategies for the Planning and Design of
Healthcare Facilities
This Educational Session Presented by :
The American College
of Healthcare Architects
Improving medical care
Environments through
Specialty Certification of
Healthcare Architects
Slide: 1

ACHE CONGRESS 2006
Chicago, March 27- 30
The Bottom Line
on Evidence-Based Design
Presented by:
Joan Saba, AIA, FACHA
Principal, NBBJ
&
D. Kirk Hamilton, FAIA, FACHA
Associate Professor, Texas A&M University
Slide: 2

Emerging Trends & Successful Strategies for the
Planning and Design of Healthcare Facilities
Part Two:
“The Bottom Line on
Evidence-based Design”
Joan Saba AIA, FACHA
• Principal: NBBJ Architects, New York City
• Past President, AIA Academy of Architecture for Health
• Frequent Presenter on Healthcare Design Issues
D. Kirk Hamilton, FAIA, FACHA
• Assoc Professor of Architecture, Texas A&M University
• Founding Principal: Watkins Hamilton & Ross Architects
• 35 Years experience in Healthcare Architecture
• Past President, ACHA
Slide: 3

Evidence-Based Medicine
“Evidence-based medicine is the conscientious,
explicit and judicious use of current best
evidence in making decisions about the care of
individual patients.”
Sackett, DL; WMC Rosenberg; JA Muir Gray, RB Haynes & WS Richardson
(1996) “Evidence-Based Medicine: What it is and what it isn’t”
British Medical Journal 312: 71-2.
– making decisions
– individual projects patients
– current best evidence
Slide: 4

What is Evidence Based Design?
Slide: 5

Evidence-Based Design Practice
Evidence-based designers make
critical decisions, together with an
informed client, on the basis of the best
available information from credible
research and the evaluation of
completed projects.
Hamilton, DK (2003) “The Four Levels of Evidence-Based
Practice,” Healthcare Design, November, 3:18-26.
Slide: 6

Evidence-Based Medicine
• “Evidence-based medicine (EBM) requires the
integration of the best research evidence with our
clinical expertise and our patient’s unique values and
circumstances.”
Straus, SE; WS Richardson; P Glasziou & RB Haynes (2005) Evidence-
Based Medicine, 3rd ed. Elsevier: Oxford.
• Design Corollary: Evidence-based design (EvBD)
requires the integration of the best research evidence
with our design expertise and our client’s unique
project goals and context.
Slide: 7

What is the Role of the Environment in Healing?
• A healing environment is the result of
an evidence-based design that has
demonstrated measurable
improvements in the physical and/or
psychological states of patients and/or
staff, physicians, and visitors.
• A healing environment is a
complementary treatment modality that
makes a therapeutic contribution to the
course of care.
Slide: 8

Evidence Based Design = Performance Based Design
• Our Client’s Environment
• Drivers of Performance Based Design
– Environment + Performance
– Vision + Performance
– Performance + Process
– Emerging Performance Measures
Slide: 9

Why Do Evidence Based Design?
The Stakes are Too High Not To.
Medical Errors
Quality and Safety
Staff Retention
Competition
Financial Performance
Clinical Performance
Patient Outcomes
Slide: 10

Medical Errors
Up to 1/3 of healthcare spending is wasted because of
redundant or wrong care
• Medical errors kill 44,000 – 98,000 Americans per year
• Gaps in care environmental impact
• Institute of Medicine Report on Medical Errors
– Patient safety
– Building a culture of safety
• Design opportunity to lessen medical errors
– Med room design
Slide: 11

Quality and Patient Safety
1. Care is based on continuous healing
relationships.
2. Customization based on a patient’s needs and
values.
3. The patient as a source of control.
4. Shared knowledge and the free flow of
information.
5. Evidence based decision making.
Slide: 12

Staff Retention
• If the environment of care is toxic,
nurses will leave, patients will suffer,
and in the end, hospitals will lose the
money they are trying to save.
(Aiken et al. 2002)
The Nurse
by Roy Litchenstein
Slide: 13

Staff Retention
Reduced staff stress and fatigue and
increased effectiveness in delivery of care
• Provide good ventilation – healthy work environment
• Reduce noise – provide a quiet work area
• Walking distances - reduce foot fatigue and repetitive steps
• Reduce staff turnover
• Reduce staff injuries, (patient handling)
Slide: 14

Staff Retention and Attraction
Griffin Hospital The SLAM Collaborative
Slide: 15

Fortune 100 Best List
• #1 Edward Jones (stockbrokers)
• #2 The Container Store
• #3 SAS Institute
• #28 Microsoft
• #43 Griffin Hospital
• #58 Starbucks
• #74 Harley-Davidson
• #94 Wal-Mart
Slide: 16

Relationship of Employee to Patient Satisfaction
Source: Press-
Ganey
Slide: 17

The Business Case for Planetree at
Griffin Hospital: Human Resources
Recruitment of like-minded staff
- 3.8 % R.N. vacancy rate vs. 15% in the region;
- RN turnover 50% of nat’l. rate
- Estimated annual savings of $662,500 in nursing
recruitment, replacement and training costs
- 2.8% overall staff vacancy rate
- Sick Time Use – below national average at 5.6 days avg./yr.
- Attract better qualified doctors and medical interns and
residents
- Fortune designation as “employer of choice”
Slide: 18

Number of Claims- All Departments
35
30
25
20
First Year of Planetree
Participation
15
10
5
0
2001 2000 1999 1998 1997 1996 1995 1994
2001 2000 1999 1998 1997 1996 1995 1994
Claims 18 22 29 30 34 32 29 26
Slide: 19

Patient Claims
[By Policy Years 1994 – 2001]
All Departments
Open Charts and Care
Conferences Fully
Implemented
15000
Adjusted Discharges vs. Number of Claims
35
12000
30
25
9000
20
6000
15
3000
10
5
0
2001 2000 1999 1998 1997 1996 1995 1994
Adj. Disc. 12,441 11,242 9,830 9,319 8,907 8,830 9,833 10,033
Claims 18 22 29 30 34 32 29 25 Slide: 20
0

Financial Performance
• “Down Stream” application
• Colonoscopies
Studies for 50 + year old show a
dramatic decrease in rate of advanced
colon cancer
• Everyone brought in: insurers,
admin, physicians
• Number of cases surged
• Straight affect on design
Slide: 22

Patient Outcomes
• Cardiac CT vs., Cardiac Catheterization
• Mt. Sinai NYC study
– Patients with no symptoms but with 20%
risk factor
– In next 4 years- 10% population over 30
years old
• CT angiography $600/procedure,
15 minutes
• Diagnostic Cath $3,000/procedure,
60 minutes
• GE: 75% of multi-slice scanners sold have
cardiac applications
Modern Healthcare 12/1/03
Slide: 23

Sources of Evidence Based Design
Slide: 24

Sources of Data
• Pebble Partner Project data from CHD
www.healthdesign.org
• Coalition for Healthcare Environmental Research
www.cheresearch.org
• Texas A & M, Georgia Tech, Clemson
• RWJ Foundation research studies
• AIA, ACHA, IIDA, AAHID
• Conferences: Health Design, Symposium on Health
Design, International Academy for Design and Health,
Praxis One
• ACHE, NACRI, and healthcare specialties organizations
and their annual conferences
Slide: 25

Methodology to Implement EvBD Process
• Set design goals and objectives
• Identify key design issues
• Research key issues & benchmark relevant examples
• Use critical thinking to explore complicated implications
of the research on the project
• Hypothesize the intended result(s) of the design
• Select appropriate measures to determine whether the
hypothesis is supported
• Construct the building or physical environment
• Carefully measure the results
• Report unbiased findings from an independent source
• Subject findings to peer-reviewed scrutiny
Slide: 26

Data Collection Tools
• Behavioral mapping & time-elapse filming to evaluate
efficiency of operational model and unit design
• Supplement Press-Ganey survey questions for ratings in
target areas
• Data analysis of patient metrics (pain mgmt,
error/omissions tracking, LOS tracking, etc..)
• Utilize graduate students for data collection & analysis
• Document “operational” & “experiential” benchmark
conflicts
• Operational modeling for patient through-put or nurse
metrics
Slide: 27

Decision Matrix from CHD Pebble Program
Comparative Group
Outcome Researched
Patients
(S, G, or A)
Employees/
Physicians
(S, G, or A)
Family/Visitor
(S, G, or A)
Community
Organization/
Institution
Economic/Financial
Resource Utilization
N/A N/A N/A N/A
Operational
Improvements
Satisfaction/
Quality of Life
N/A
Cultural Assessment
Safety/Error Reduction
Outcomes
N/A N/A N/A
Outcome Researched
Environmental Issues/
Sustainability
Wayfinding
Other Measurable
Outcomes
S=same G=group A=all
Slide: 28

What Do We Know?
Slide: 29

EvBD Research - 2004 Literature Search
• Center for Health Design &
Robert Wood Johnson
Foundation
• Texas A&M, Georgia Tech
• Ulrich & Zimring metaanalysis
• 650+ studies
• Published report, webcast
Ulrich, RS, C Zimring, A Joseph, X Quan, & R Choudhary (2004). The role of the physical environment in the
hospital of the 21st century: A once-in-a-lifetime opportunity. Concord, CA: The Center for Health Design.
Slide: 30

EvBD Research - 2004 Literature Search
Rigorous studies link the environment to
outcomes in four areas:
1. Reduce patient stress & improve outcomes
2. Reduce staff stress & fatigue
3. Improve safety
4. Improve quality
Slide: 31

Reduce Patient Stress & Improve Outcomes
• Reduce noise
• Improve sleep
• Reduce spatial disorientation
– Administrative & procedural information
– External building cues
– Local information
– Global structure
• Reduce depression
• Provide nature and positive distractions
– Gardens in healthcare environments
– Art in healthcare environments
• Provide social support
• Improve communication to patients
Slide: 32

Patient Stress Scorecard
Ulrich & Zimring, 2004
Reduce stress, improve quality of life and
healing for patients and families
Reduce noise stress
Reduce spatial disorientation
Improve sleep
Increase social support
Reduce depression
Improve circadian rhythms
Reduce pain (intake of pain drugs, and reported pain)
Reduce helplessness and empower patients & families
Provide positive distraction
Patient stress (emotional duress, anxiety, depression)
Slide: 33

Staff Stress Scorecard
Ulrich & Zimring, 2004
Reduce staff stress/fatigue, increase
effectiveness in delivering care
Reduce noise stress
Improve medication processing and delivery times
Improve workplace, job satisfaction
Reduce turnover
Reduce fatigue
Work effectiveness; patient care time per shift
Improve satisfaction
Slide: 34

Patient Safety Scorecard
Ulrich & Zimring, 2004
Improve patient safety and
quality of care
Reduce nosocomial infection (airborne)
(contact)
Reduce medication errors
Reduce patient falls
Improve quality of communication (patient staff)
(staff staff)
(staff patient)
(patient family)
Increase hand washing compliance by staff
Improve confidentiality of patient information
Slide: 35

Quality Scorecard
Ulrich & Zimring, 2004
Improve overall healthcare quality
and reduce cost
Reduce length of patient stay
Reduce drugs (see patient safety)
Patient room transfers: number and costs
Re-hospitalization or readmission rates
Staff work effectiveness; patient care time per shift
Patient satisfaction with quality of care
Patient satisfaction with staff quality
Slide: 36

Research Conclusions - Immediate Action
• Provide single-bed rooms
• Hospitals should be much quieter to reduce stress
& improve sleep
• Provide stress reducing views of nature
• Develop efficient wayfinding systems
• Improve ventilation
• Improve lighting
• Design to reduce staff walking & fatigue
RS Ulrich (2004) “Opportunity of a Lifetime: Meta-
Washington, DC.
analysis of the literature,” RWJF presentation at the National Press Club,
Slide: 37

Examples of Evidence Based Design
Hospitals Use the Data
• Griffin Hospital
•Mass General
Project Planning -
• Performance Measures:
part of the Planning Process
• Mandatory Practice
Slide: 38

Mass General Hospital
Building 2 Patient Bed SD User Meeting 2
Slide: 39

Slide: 40

Performance Goals - Beds
1. Satisfaction with facility on the part of patients, staff, and
families
2. Perceived impact on work flow/productivity
3. Staff nurse injury rates (OCC Health and Ergonomic
Specialists)
4. Increase patient and staff safety
Reduce number of falls
Reduce number of injuries
Reduce medication errors
Slide: 41

Examples of Evidence Based Design
Healthcare Design Firms
- Design firms’ evidence based studies
-cross section of experience
-benchmarking of information
-outcome comparisons
Slide: 42

Pavilion for Women and Children, WA
Blank Children’s Hospital, Iowa
•The NICU has 23 singlepatient
rooms (3 doubles for
twins)
– 6 level III
– 17 Level II
•Each Private Room has / is:
– sleeper
– rocking chair
– adjacent to nursing station
Slide: 43

Sound + Performance… Decrease Noise Levels
– Both units have patients, visitors and staff
comment on quietness and calmness
– Quietness invokes quietness
• families and staff are quieter
– Blank has carpeted hallways and rooms
– Providence has carpeted hallways
– Less cycling of “noisy babies”
– Nuisance alarms are down
– Nurses are “learning to talk lower”
Impact of controlled light and noise on ventilated infants; reduced blood pressure,
arterial pressure & movement (Slevin, et al., 2000).
Slide: 44

Sound + Performance… Decrease the ALOS
“I think the babies love their
new rooms. I will be
anxious to see if we get a
decrease in LOS because
our babies are sleeping
better” (Blank Caregiver
Survey)
Decreased LOS with an increase in patient acuity
Slide: 45

Performance of Single Room NICU’s…
for the neonate
– decrease the noise level on the unit
– decrease nosocomial infections
– decrease ALOS
– decrease use of sedation
– improve control of room temperature
– decrease light per bassinet
– decrease readmit rates
– improve patient outcomes
Slide: 46

Performance of Single Room NICU’s…
for the parents
• increase time parents spend with their baby
• empowers parents in “care” of baby
• increase parent satisfaction of care
• increase parent/patient confidentiality
Slide: 47

...increase time parents spend with their babies
Slide: 48

Single Room NICU’s … for hospitals and staff
– increase staff job satisfaction.
– decrease nursing hours per neonate.
– improve hiring ability.
– improve supply tracking and charges.
– increase overall operating costs due to increased
square footage of the unit.
– increase neonatologists hours of care per neonate.
Slide: 49

Improved Staff Job Satisfaction
This is what we
worried about!!!!
All measures
are at or
above 2000
levels!
Slide: 50

Improve Staff Job Satisfaction
Perceived Patient Experience
Caregiver Experience
Slide: 51

Operational Cost Impact
New Unit
opened in
2002
Slide: 52

Increase Overall Costs (Increased sq. ft)
– Current average rule of thumb for Departmental Gross
Square Feet (DGSF) per Bassinet is 400-600 square feet
– Average of sample recent “open bay ICU’s = ~420
DGSF/Bassinet
– Blank = 490 DGSF/Bassinet
– Providence = 510 DGSF/Bassinet
How much more?
Providence: 90 x 29 = 2,610 DGSF x $260 = ~$679,000 (21% Premium)
Blank: 70 x 35 = 2,450 x $180 = ~$441,000 (14% Premium)
Slide: 53

Examples of Evidence Based Design
International
- NHS Estates Patient Surveys
- Picker Institute International
-Performance Focus
Slide: 54

NHS Estates Nurse Survey
The Role of Hospital Design in the Recruitment, Retention and Performance of NHS Nurses in England,
Report July 2004
Slide: 55
PricewaterhouseCoopers LLP in association with the University of Sheffield and Queen Margaret University
College, Edinburgh

Examples of Evidence Based Design
Other Hospital Services
Information: hardware, software and people-ware
AHRQ: $87 billion would be
saved annually if IT was
standardized in HC across the
US - let alone the decrease in
errors and increase in efficiency
Agency for Healthcare Research and Quality
Slide: 56

Evidence Based Design Process
Slide: 57

Evidence-Based Design Process
TASK
ACTIVITY
1 Identify the client’s goals Note most important and facility-related
global and project-based goals
2 Identify designer’s goals Understand designer’s strategic,
project, and evidence-based design
objectives
3 Identify the top 3-5 key design issues Narrow the possible choices;
work on high impact decisions
4
Convert design issues to research
questions
Reframe statement of design issues
to become research topics
5 Gather information • WHR’s studies Infinite possibilities must be narrowed;
limited perspectives must be expanded
6 Critical interpretation of the evidence No direct answers; requires openminded
creativity, balance and critical
thinking
7
• Benchmark examples
• Literature sources
Create evidence-based design
concepts
Based on creative interpretation
of the implications of research findings
8 Develop hypotheses Predict the expected results from
implementation of your design
9 Select Measures Prove or disprove your hypotheses
Slide: 58
© Kirk Hamilton & WHR Architects 14 July 2005

Evidence-Based Design
• How do you
decide what to
research?
• We can’t study
everything…
FLIP A
COIN
little known
low impact
little is known
decision
is important
DO THE
RESEARCH !
high
Degree of
Uncertainty
DO WHAT
YOU WANT?
good information
low impact
low
good information
important decision
Impact of Decision
high
low
GET IT
RIGHT
Slide: 59

Design for Outcomes
1. Internal Performance
Operational Efficiency
Improve Clinical Outcomes
Patient Safety
2. Service Delivery
Customer Satisfaction
3. Learning and Growth
Workflow Development
4. Financial Performance
Profitability
Revenue and/or
Market Share Growth
Slide: 60

Operational Efficiency
Reduce Staff Travel/
Improve Flow
Improve Communication
Between Physicians
(offices) and Other Clinical
Staff
Bedside/ point of care
documentation; Acuity –
adaptable rooms; larger
doorway size for obese patient
bariatric beds
Digitally-based technology
(paperless, transfer); Wireless
internet/ intranet; Multiple
charting stations
Time-Motion study of staff
activities; # of transfers per
day/month/ year; Staff time/cost
per transfer (vs. baseline)
Supply purchasing; Medication
errors; Patient care vs.
administrative staff time ratio(s);
cost per unit of service
Reduce/ Minimize Supply-
Related Activities
(“hunting and gathering”)
Reduce / Minimize Patient
Transfers & Transport
Decentralized supplies and
equipment; Inventory-locating
software; Larger/separate
narcotics & medication room;
Decentralized and/ or in-room
charting stations
Decentralized ancillary services;
Acuity- adaptable rooms;
Administrative –patient time
ratio; Supply waste (spoilage,
loss); Medication/medical errors;
cost per unit of service
# of transfers per
day/month/year; Staff time/cost
per transfer (vs. baseline); Staff
injury/sick times and/ or L&I
claims/ premiums; Nosocomial
infection rates; Patient falls;
Medication errors; Patient
(dis)satisfaction; Patient
throughput
Slide: 61

Profitability
Improve Supply
Management: materials and
equipment –convenient
access, known location
Reduce need to renovate
space as uses change,
grow or are replaced;
Extend useful life of facilities
Decentralized supply storage;
Equipment locating software;
Acuity- adaptable rooms;
Decentralized nursing stations
Flexible space design; Modular
construction; Modular interiors
Variable costs (supplies,
medications, incidentals); Labor
costs (FTE’s); Room turnaround
time; Various staff productivity
Debt service/ leverage ratios;
External financing requirements;
Service line capacities; Patient
“re-directs”; # of technology
generated renovations
NBBJ
Slide: 62

Case Studies
Valley View
Clarian Methodist
Emory ICU
Rockingham
Slide: 63

Valley View Regional Medical Center
Cedar City, Utah
Multi-modality
Diagnostic &
Procedure Centers
Architect: WHR & GSBS
Mountain Health Design
Attached Physician Offices
13.8% sustained reduction in FTEs/adjusted occupied bed
Slide: 64

Valley View - Organizational Redesign
Management
Hypothesis
A degree of change
NOT possible without
a new building
Slide: 65

Case Study
Cardiac Comprehensive
Care Center
Clarian Methodist Hospital
Indianapolis, Indiana
BSA Architects
• $7+ million 56-bed unit (2
floors of 28) opened
February 1999
• Constructed in shell space
• Patient-centered nursing,
decentralized charting
• Acuity adaptable unit is both
CCU and stepdown
• Private ICU rooms with
conventional headwall
• Family accommodations
Source: A. Hendrich (2004)
Slide: 66

Slide: 67

Flat Screen Monitoring
Blood Analysis Modules
Infra-red tracking for Nurse
Call and Nurse Location
ICU
capable
Headwall
Phone/
Modem
Electronic LCD Window
Observation vs. privacy
Nurse Work
Station
Hand Washing
Sink
Family Zone
Patient Education
Comprehensive Cardiac Critical Care
Slide: 68
CCCC-1 st Generation of Change

BSA Architects
Acuity-Adaptable Adaptable Room Clarian Methodist, Indianapolis
Slide: 69

Areas of Measurement
• Clinical outcomes
• Satisfaction
• Education
• Personal growth
• Cost
• Efficiency
Results
• 75% drop in falls
• 90% reduction in unit-tounit
transfers
• Patient dissatisfaction
dropped from 6.7% to
3%
• Improved medication
error index
• Reduced caregiver
workload index
Slide: 70

Annual Medication Error Index
(errors/patient days)
Index
12
10
Move
Feb. 99
8
6
4
2
0
CCU and A3North CCCC opened
1997 1998 1999 2000 2001
Med Errors
Slide: 71

Annual Patient Fall Index
(falls/patient days)
Index
7
6
5
4
3
2
1
0
Move Feb. 99
1997 1998 1999 2000 2001
CCU and A3North CCCC opened
Slide: 72

Patient Dissatisfaction Level
Overall Patient Dissatisfaction
6
5
Move
Feb. 99
Table 6
Percent Dissatisfied
4
3
2
1
0
1997 1998 1999 2000 2001
CCU and A3North CCCC opened
Slide: 73

Direct Paid Nursing Hours Per Patient Day
Direct
Hours
20
18
16
14
12
10
8
6
4
2
0
•Case Mix Index
•Nurse Acuity
12.4
*
1.5
•
1.6
14.8
*
1.5
•
1.4
17.8
*
1.6
•1.6
13.66
*
1.5
•
1.6
*
1.6
•
1.6
12.94
1997 1998 1999 2000 2001
CCU and A3North CCCC opened
Slide: 74

Intra-unit Patient Transfers
Implications for Hospital Design
• Involves
– Nursing time
– Waste and duplication
– “Hiccups” in care
– Additional equipment
– Average minimum total
direct time for transport
• 25 minutes to 48 hours
Transports per Month
250
200
150
100
50
300
200
100
0
1997 1998 1999
Tra nspo rt
Transports
0
1997 1998 1999 2000 2001
CCU and A3North CCCC opened
Slide: 75

Annual Patient Days Per Bed = 7 Less Beds
Capacity and Bed Efficiency
350
300
250
63 Beds
56 Beds
Patient Days
200
150
100
50
0
1997 1998 1999 2000 2001
CCU and A3North CCCC opened
Slide: 76

Publication of Findings
• Hendrich, A. (2003a). Case Study: The impact of Acuity Adaptable rooms
on future designs, bottlenecks and hospital capacity. Paper presented at the
Impact Conference on optimizing the physical space for improved
outcomes, satisfaction and the bottom line, Atlanta, GA.
• Hendrich, A., Bender, P. S., & Nyhuis, A. (2003). Validation of the Hendrich
II Fall Risk Model: a large concurrent case/control study of hospitalized
patients. Applied Nursing Research, 16(1), 9-21.
• Hendrich, A., Fay, J., & Sorrells, A. (2002). Courage to heal:
Comprehensive Cardiac Critical care. Healthcare Design, 11-13.
• Hendrich, A., Fay, J., & Sorrells, A. K. (2004). Effects of Acuity-Adaptable
Rooms on Flow of Patients and Delivery of Care. American Journal of
Critical Care, 13(1).
Slide: 77

Example of a Relevant Study
• Comparison of handwashing compliance in three ICU
settings: Xiaobo Quan, PhD student @ Texas A&M
– 1) open bay,
– 2) older private room,
– 3) larger private room w/ sink near door
• Preliminary findings: compliance increased over open
bay in both private rooms, by 70% in well-designed
room
• Implication: design more effective than special training
in compliance
Slide: 78

Case Study
• Design for unit questioned
• Experts invited to review
Neuro ICU
Emory University
Atlanta, Georgia
• Evidence gathered
• Team explores implications
in “charrette” workshop
• Redesign of unit
Source: Owen Samuels, MD,
Craig Zimring, PhD (2005)
Slide: 79

Design Drivers, Design Responses & Outcome
Measures
Support families
•Family zone in patient room
•Kids’ room
•Lockers & showers
•Family quiet room
•Greater satisfaction on Press Ganey and
Emory ICU survey
•Fewer complaints & litigation
Support more
procedures at the
bedside
•Medical gas booms
•Larger patient zone
•Improved ergonomics
•Less patient transfer complications and costs
•Fewer errors
•Shorter stays
•More time spent by ICU staff in the ICU area
Reduce infection
•Numerous rubs and handwashing
stations
•Improved handwashing compliance
•Lower MRSA and nosocomial infection rate
Reduce medical errors
and increase patient
safety
•Improved ceiling tiles
•Carpet where appropriate
•Charting niches
•Zoned caregiver zone
•Fewer medical and medication errors
•Less litigation
•Reduced self- extubation
•Decreased falls and injuries related to
patients leaving beds
Slide: 80

Patient room size
MGH
Patient Room Size Analysis
Slide: 81
500
450
400
350
300
250
200
150
Square footage
100
50
0
Emory Neuro-ICU 6A
Emory Neuro-ICU 3G
Legacy Good Samaritan Hospital
Mayo Medical Center Saint Marys Hospital
Washington Adventist Hospital
Harris Methodist Fort Worth Hospital
Rochester General Hospital
Clarian Health Group Methodist Hospital
Massachusetts General Hospital (MGH)
Hospitals

Best Practices Analysis
Features in Family Waiting Areas
St. Lukes St. Eliz. Mayo Mayo-Litta Clarian Harris Arkansas
Adjacent to ICU x x x x x 5
Inside ICU x x 2
Family Waiting Area x x x x x x x 7
Children's Space x 1
Consultation Rooms x x x x 4
Refreshments x 1
Kitchenette x x x x x 5
Quiet Rooms x x 2
Private Family Rooms x x 2
Lockers x x 2
Adjacent Restrooms x x x x x 5
Showers x x 2
Garden Space x 1
Laundry x 1
6 5 6 5 5 5 8
Slide: 82

Typological Analysis: Clustering
Clusters of 5 patient beds
with self-contained nursing
stations
Clusters of 10 patient beds
Slide: 83

Typological Analysis: Family Area
Family area outside the unit
Family area inside the unit
Slide: 84

July 2005 Charrette: EUH, GT, HKS
Slide: 85

Private
family area
Larger Patient
room
Shower and
laundry for family
AFTER
Workstation
Kid zone
Healing garden
BEFORE
Slide: 86
Patient room Family waiting area Nurse station

New Floor Plan
Caregiver
entry
Family
entry
Shower and
laundry for
family
Healing
garden
Private
family area
Distributed nurses’
stations designed to
support specific
activities
Workstations
Slide: 87

Slide:
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88
Rockingham Memorial Hospital
Space
Planning
Operation
Planning
Tech
Planning
Rockingham
Memorial
Hospital
Private
Rooms
Same
Handed
Rooms
Standard
Unit
Layout
Enhance
Patient
Visibility
Two Level
Care Plan ;
Acuity
Adjustable
Diagnosis
Related
Cohorts
Redesign
Flow
Align
Resources
EMR Tracking CPOE Communication
System
Monitor-ing
Safety Concerns
Medication Error
Reduces
error
Reduces
error
Reduces
error
Reduces
error
Reduces
error
Reduces
error
Reduces
error
Reduces
Error
Reduces
Error
Reduces
Error
Nosocomial
Infection
Reduces
infection
Reduces
infection
Reduces
infection
Reduces
infection
Reduces
infection
Reduces
infection
Patient Falls
Reduces
falls
Reduces
falls
Reduces
falls
Reduces
falls
Reduces
falls
Reduces
falls
Reduces
falls
Patient Restraint
Enhance
safety
Enhance
safety
Enhance
safety
Enhance
safety
Information Transfer
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Reduces
Gaps
Patient Outcomes
Improves
Outcome
Improves
Outcome
Improves
Outcome
Improves
Outcome
Improves
Outcome
Improves
Outcome
Improves
Outcome
Improves
Outcome
Improve
s
Outcom
e
Improves
Outcome
Improves
Outcome
Improves
Outcomes
Patient Transfers
Reduces
transfers
Reduces
transfers
Reduces
transfers
Reduces
transfers
Reduces
transfers
Reduces
transfers
Reduces
Transfers
Patient Security
Improves
Security
Improves
Security
Improves
Security
Improves
Security
Improves
Security
Improves
Security
Improves
Security
Surgical
Complications
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-
Reduces
Complic-

Bringing it all Together
Efficiency and Cost Savings Design Concepts
Rockingham
Memorial
Hospital
Space Planning Operation Planning Technology Planning
Design Concepts
Efficiency Concerns
Private Rooms
Same Handed
Rooms
Standard
Unit
Layout
Medication Administration Reduces errors Consistency
Patient Access
Patient Flow
Easy
admission; bed
management
Reduces delay
Improves staff
practice;
effectiveness
Consistency
Organizational Structure Care models Span of control
Information Transfer
Practice Patterns
Length of Stay
Supply Management
Enhances
accuracy
Facilitates
patient / family
interaction
Decrease due
error, infection
Enhances
accuracy and
good technique
Decreases
error and LOS
Consistent set
up of
procedures
Location of
information
Fosters
consistent
practice
standards
Supports
efficient
processes
Enhance
Patient
Visibility
Patient
placement
Effective FTE
utilization
Hierarchy of
work stations
Decrease falls
Two Level Care
Plan ; Acuity
Adjustable
Reduction
waste
Consistent
admission
process
Reduces
transfers
High
competency
Limits
redundancy
in
Admission and
discharge
criteria
Consistent
care planning
activities
Decrease
variety of
supplies per
unit
Diagnosis
Related Cohorts
Reduce
stock
Eases
appropriate
placement
floor
Support for
patient needs
High
competency
Enhances
Physician
communication
Enhanced
patient
outcomes
Expertise in
staff for DRG
Decrease
variety of
supplies per
unit
Redesign
Flow
Streamlined;
reduced
rework
Streamline
process; one
stop shopping
Optimize work
flow to meet pt.
needs
Maximize FTE
utilization
Reduces
requirement of
info transfer
Moves
resources to
the patient
Eliminate gaps
Ease of supply
use and
ordering.
Decrease
hording
Align
Resources
Right person;
right job
Right person;
right job
Conservation
of resources
Cross
functional
teams
Right person;
right
information
Right person ;
right timer
Collaborative
practice
Appropriate
use of FTE and
skill set
EMR Tracking CPOE
Automated
MAR; reduced
labor hrs.
Clinical
repository
Communicatio
n of events and
activities
Automated
capture of
complete
information
Information
available
regardless of
location
Availability of
information
Capture use
and charges
Facilitates
patient
movement
Facilitates
patient
movement
Data driven
decisions
Automated
capture and
reporting
Provides data
to adjust
practice
Decreases
LOS in
procedural
based
departments
Eliminates
gaps & rework
Eliminates
gaps & rework
Role
redefinition
Direct from
Physician to
provider of
service
Standardize
order sets. AI
Timely
treatment
Communication
System
Eliminate gaps
Notification;
eliminate gaps
Notification;
eliminate gaps
Eliminates
gaps;
facilitates team
function
Facilitates
team patient
goals
Facilitates
team and
activities
Bar coding to
vendor etc. jit
Monitoring
Maintain
Trendline
Fosters
appropriate
cohorts
Maintain
trendlines
Fosters
appropriate
cohorts
Reduces
transfers ( .5
day / move )
Lower par
levels, assure
supply
availability.
Standardizati
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MUSC Persona Detail
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Our Mutual Responsibility
• IF architects are responsible for
health facility design,
• and IF credible evidence indicates
design can improve clinical
outcomes & patient safety,
• THEN healthcare architects have a
moral responsibility to utilize such
evidence…
…and responsible executives
must make it possible!
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Emerging Trends & Successful Strategies for the
Planning and Design of Healthcare Facilities
Bibliography: Evidence Based Design
Ulrich, R, C Zimring, X Quan, A Joseph & R Choudhary. (2004) The Role of the
Physical Environment in the Hospital of the 21st Century, The Center for Health
Design, Martinez, CA, (2003)
Hendrich, A.L., Fay J., Sorells A.K. Effects of Acuity-Adaptable Rooms on Flow of
Patients & Delivery of Care, American Journal of Critical Care, Vol. 13, Jan 2004
Healthcare Financial Management Association Price Waterhouse Coopers, 2004
Survey
The Role of Hospital Design in the Recruitment, Retention and Performance of NHS
Nurses in England, Report July 2004, PricewaterhouseCoopers LLP in association
with the University of Sheffield and Queen Margaret University College, Edinburgh
Websites:
www.healthdesign.org – Center for Health Design, Pebble Projects results
www.pickerinstitute.org – Picker Institute Europe
www.nhsestates.gov.uk – Patient Surveys
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Emerging Trends & Successful Strategies for the
Planning and Design of Healthcare Facilities
Speaker Contact Information:
Joan Saba AIA, FACHA
NBBJ Architects
85 Fifth Avenue New York, NY 10003
212-924-9000
jsaba@nbbj.com
D. Kirk Hamilton, FAIA, FACHA
Texas A& M University
TAMU 3137 College Station, TX 77843
797/862-6606
khamilton@whrarchitects.com
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