Framing the Issue:
• Hospitals can be designed to improve patient safety, from falls to medication errors.
• Avoiding errors, reducing lengths of stay and readmissions, and improving the patient experience are all affected by the built environment and are important factors under emerging value-based payment models.
• By creating a multidisciplinary team to consider facility design, including architects, designers, executives, clinicians, technology staff, the public and others, hospitals enhance their chances for effective design.
• Mock-ups of construction projects allow testing of design choices by staff and patients to promote safety and efficiency.
• Safety risk assessments are important steps to take from the beginning of the planning process.
Barry Rabner, president and CEO, Princeton HealthCare System, says the design process for his organization’s new hospital, University Medical Center of Princeton at Plainsboro (N.J.), helped him to understand the relationship between good design and quality care.
“It was a really big discovery for me that the building was more than just a container that would hold people and things, but that it could, in fact, be designed in a way that could help us to achieve important goals,” says Rabner.
The project’s goals included reducing the number of errors, falls and infections at the facility and improving patient outcomes, patient and family satisfaction and the hospital’s financial performance. Safety was considered important to all of these. A safe environment “results in better clinical outcomes, reduced cost and higher satisfaction,” Rabner says. “And if you design the building well, as we’ve now come to learn, it really can deliver on those objectives.”
Safety issues affect nearly every area of facility and organizational performance. Cyndi McCullough, R.N., director of clinical services for design firm HDR, says that when her firm starts a facility design, one of the first steps is to help clients define a vision and guiding principles for the project. “Safety is typically No. 1,” she says.
Federal regulations concerning reimbursement and reporting underscore this, McCullough says. The Centers for Medicare & Medicaid Services does not reimburse health care providers for “never events,” errors CMS considers reasonably preventable, and the Hospital Readmissions and Reduction Program requires CMS to reduce payments to hospitals for readmissions the program deems excessive. The national HCAHPS survey is a public accounting of patients’ experience of care, including their perceptions of staff responsiveness and the hospital environment. A number of adverse events can be related to the building, McCullough notes. Falls, medication errors and health care-associated infections each can be impacted by the design, technology and products used in a facility.
The new bed tower at Central Washington Hospital in Wenatchee is a recent HDR project that combines design and technology to enhance safe operations. The tower features standardized, same-handed, acuity-adaptable patient rooms with large windows and dedicated space for family and visitors. Patient lifts that can support up to 1,000 pounds are provided in bariatric rooms. Every bed can weigh patients; beds in the intensive care unit include programming that can translate simple commands in five languages, play comforting music and tell patients to return to bed if they try to get up.
Decentralized nurse stations are located between every two rooms, and nurse servers in each room store common supplies. The nurse call system, which utilizes wireless phones as communication devices, has a nurse-locater function that activates a color-coded, light-emitting diode panel at the door to each patient room indicating the type of patient call and whether a registered nurse or certified nurse assistant is in the room.
WellStar Paulding Hospital, Hiram, Ga., designed by CDH Partners, is another facility for which safety was a prime directive during design. Hospital President Mark Haney explains that the hospital developed a program called “safety to the fourth power” to lead design decisions. This involved considering the safety of patients and their families, hospital staff, the community and the environment. “That was the banner they carried throughout the project,” says Mary Lindeman, senior project manager at CDH Partners.
The facility is a zero-threshold building, with every transition between rooms flush so as not to impede shoes, wheelchairs, walkers or any other form of hospital transport. A handrail with a built-in nightlight leads from the patient bed to the bathroom. Patient lifts are installed in the bariatric and ICU rooms; all patient rooms include the necessary infrastructure to add lifts in the future. Hand-washing sinks are distributed throughout the facility, in places like corridors and caregiver team areas, in addition to patient rooms.
A hand-wash monitoring system that uses radio-frequency identification technology is in use at the hospital. The patient rooms are equipped with nurse servers, as well as bedside charting and medication scanning technology. By designing the facility to limit staff interruptions and allow nurses to remain close to patients, the project team endeavored to return two hours a day to caregivers for direct patient care, Haney says.
Grinnell (Iowa) Regional Medical Center is studying the use of copper alloy surfaces to reduce bacteria load, as one of several safety initiatives underway at the hospital, says Todd Linden, president and CEO. Earlier clinical trials funded by the Department of Defense have indicated a link between reduced infection and copper touch surfaces.
Following the same study protocol as the DoD, Grinnell Regional Medical Center is partnering with Olin Brass, Louisville, Ky., to install a number of products utilizing the company’s CuVerro bactericidal copper surfaces in 12 of the hospital’s 23 medical-surgical patient rooms. These include bathroom grab bars, toilet flush handles, sinks, faucets, door and cabinet hardware, IV poles, light switches and bedside and overbed tables. Initial swabbing started in April to establish baseline readings; random tests are taking place this fall to compare the bacteria load in the rooms with CuVerro surfaces against those without.
CuVerro is registered by the Environmental Protection Agency for the material’s inherent effectiveness in killing bacteria. Standard environmental services protocols are used to clean CuVerro, so it does not require additional labor to maintain, does not introduce chemicals into the facility and is not harmed by typical hospital cleaners, Linden notes.
He says the hospital hopes to learn whether copper surfaces can be used as part of a multifaceted plan for keeping facilities cleaner and patients and staff healthy. “It really is an exciting new approach to being able to reduce people’s contact with bacteria,” he says.
Process improvement and preparedness
Facility projects can be opportunities to implement new processes to improve patient safety. “That starts with an understanding of a facility or a nursing team’s existing process, and then a discussion with staff and front-line users about how we can improve that process in a new facility or a new environment. It doesn’t necessarily have to be a brand-new hospital, it can be a renovation,” says Brent Hughes, project architect with Gresham, Smith and Partners. “I think the biggest thing we can do as designers that can affect patient outcomes is to be good listeners.”
For the Miami Valley Hospital South bed tower expansion project in Dayton, Ohio, GS&P designed 16-foot-wide corridors, as opposed to the standard 8-foot width, allowing space for nursing substations and supply alcoves to be distributed along the corridors.
“How can we ensure that our caregivers are more engaged and involved in patient care? That can be as simple as making sure they’re spending time with patients instead of hunting for a specific piece of equipment,” Hughes says.
For Tampa (Fla.) General Hospital’s Bayshore Pavilion, the firm addressed emergency preparedness by designing waiting rooms and corridors that can be converted to treatment spaces in the event of a disaster. The emergency department is on the second floor of the pavilion, above the storm surge level and 100-year flood plain for the facility, which is located on an island. The emergency parking area, beneath the ED, is outfitted for use for triage or mass decontamination if needed.
A solid backbone for communication technology is also an important tool for patient safety. Fort Belvoir (Va.) Community Hospital received the 2013 DoD Quality and Patient Safety Award for integrating wireless communication technology to coordinate patient care. Using a hands-free wireless system manufactured by Vocera Communications Inc., San Jose, Calif., caregivers decreased the activation time of the hospital’s rapid-response team by 68 percent and increased the amount of critical lab values reported within 30 minutes from 36.4 to 82 percent.
Major Alicia Madore, clinical nurse specialist at the hospital, says improved communication among caregivers allows patients to be seen and treated sooner, “which will obviously result in better patient outcomes, decrease length of stay and potentially save a life.” To ensure that the system functioned throughout the building, hospital staff worked with Vocera personnel over several months to identify and eliminate dead zones by enhancing the wireless signal strength in several locations.
Madore notes that the success of this type of communications system depends on a strong voice-grade wireless system. Because this can be difficult to retrofit, she advises project teams to make it a priority in facility design. “Think about it before you break ground,” she says.
‘Frankly, it’s mission critical’
Ted Hood, senior vice president and chief operating officer for health care consulting firm GBA Inc., says health care organizations should look ahead at least five years to determine their wireless communication requirements. “Even if you’re not purchasing all the capabilities [of a system], don’t sell the infrastructure short,” he says. “Frankly, it’s mission critical. The way that facilities are currently functioning, they are more dependent on wireless communication. If that system goes down or is having issues, you’re raising your risk on patient safety. So that elevates it to a new level in the industry.”
Hood recommends that hospitals think beyond the current one or 10-gigabit network. To maintain emergency connectivity and have the network strength to meet future needs, “you need to make sure that your infrastructure can support a 100-gigabit network,” he says.
— Amy Eagle is a freelance writer based in Homewood, Ill.
Mock-ups drive safe design choices
he project team for the University Medical Center of Princeton at Plainsboro (N.J.) went beyond standard construction mock-ups to ensure that the facility’s patient room design is as safe and efficient as possible.
Princeton HealthCare System dedicated two patient rooms in an existing hospital as “live mock-ups” for the project so hospital staff could evaluate the design under real-world conditions. “We wanted something operational, to really see how it works,” says system President and CEO Barry Rabner. Approximately 60 patients were cared for in the rooms over a year and a half.
Based on that experience, including patient and family feedback, the team made nearly 300 changes to the room design. While most of those were modest, they added up “to something terrific,” says Rabner.
“The devil’s in the details,” when it comes to patient room design, notes Chris Korsh, senior principal and regional leader, health care, for design firm HOK. He says the architects were thrilled to have the opportunity to test all the different elements of the design, from the relationship between the bed and the bathroom to that of the paper towel dispenser and the hand-washing sink. “That level of detail is important to the user,” Korsh says.
Safety features of the same-handed rooms include ventilation with 100 percent fresh air; a hands-free, hand-washing sink and soap dispenser; a nurse server for storing patient supplies (with a locked area for medications); a computer for bedside charting; and a family zone with overnight accommodations. The flooring, curtains and upholstery have antibacterial properties. A handrail leads from the patient bed to the bathroom, which is located three feet from the head of the bed; the bathroom door slides for ease of operation and the handrail features a low, recessed, wall-mounted, night-light fixture. The patient beds can be lowered to 16 inches off the floor to reduce the impact of possible falls and have built-in scales, pressure-relieving mattresses and a system for contacting nurses directly if high-risk patients attempt to get up without assistance.
The new design, along with staff training and improved technology and equipment, has resulted in lower rates of falls, health care-associated infections and medication errors at the hospital. “We had clear data on our performance in the old building and have been rigorous in tracking it on an ongoing basis in the new building. And all of the measures have improved materially,” Rabner says
Before construction plans are finalized, risk assessment is becoming an imperative part of the design process for health care facilities.
Safety risk assessments are new requirements in the 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities, as well as Guidelines for Design and Construction of Residential Health, Care, and Support Facilities, published by the Facilities Guidelines Institute.
What to look for
Under the guidelines, project teams are required to conduct an SRA to identify risks involving infection control, patient handling, falls, medication safety, psychiatric injury, immobility and security.
The multidisciplinary team can consider safety as the members move through the design process. “The reality is, you have so many things to think about that it’s easy to let it slip off your radar,” says Ellen Taylor, director of research for the Center for Health Design.
To suit your needs
The SRA is not a prescriptive checklist, Taylor stresses. It is a system by which owners, users and designers can evaluate the safety of a design, taking into account the organization’s patient demographics, models of care and culture of safety.