C2 - Planning a new bed towerLean Healthcare Facility Design 11-18-08

8/7/2019 C2 - Planning a new bed towerLean Healthcare Facility Design 11-18-08

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Lean Healthcare Facility Design

November 18, 2008

James Nesbitt, MD, MMM

Project Manager, Department of OperationalExcellence

Providence Alaska Medical Center

Anchorage, Alaska, USA


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Description of PAMC

365-bed acute and tertiary care hospital inAnchorage, Alaska.

2,700 employees Over 500 physicians

Operating Revenues of $511 M

Operating Margin of 6.0% for 2007


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Overall Need

A new bed tower designed to achieveoutcomes that best serve patient

safety and well being whileeliminating waste wherever possible


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Be Proactive

Design out the 7 wastes of healthcare inadvance, while the facility is still a concept

or lines on paper. Charles Hagood, CEO, HealthcarePerformance Partners (HPP).


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Why redesign work onnursing units?

Nurses spend 31-44% of their time in direct patient care activities Nurses experienced an average 8.4 work system failures per 8-hour

shift dealing with: Medications

Orders Supplies Staffing Equipment

Nurses spend 42 minutes of each 8-hour shift resolving operationalfailures

.and we are experiencing a nursing shortage!!!

Anita L. Tucker and Steven J. Spear, Operational Failures andInterruptions in Hospital Nursing, Health Research andEducational Trust, 2006, pp. 1-20.


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What are we trying to accomplish?

Eliminate wasteful activities (hunting and gathering,rework, workarounds, hassles, etc.) through processredesign and physical space redesign

Improve care processes so that nurses can spend moretime in direct care with patients

Demonstrate that wasted time has been

reallocated to direct patient care activities (that

improve care and that meaningfully include thepatient and/or family members)

Rutherford, P, Value Added Care Process, IHIpresentation, Feb 2008


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Patient-Centered Lean Design

Value Orientation and CulturalTransformation: Define value from the patients perspective

List patient likes, dislikes, and delights

Collect patient stories

Create a mind map of the varieties of patientexperiences

Brainstorm ways for staff to work differently toachieve patient delighters and avoid patientdislikes

Spiering, K, FacilityManagement.com, October, 2008


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Value Orientation and CulturalTransformation continued:

Maintain a list of ongoing patient needs: Respect for their time Increased safety by decreasing medical errors

Promote people to people interface between

patients and staff Create a healing environment that connects

mind, body, and spiritSpiering, K, FacilityManagement.com, October, 2008


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Create a Value Stream Map (VSM) of

daily activities inside the hospital:

Identify all the actions required from admission to

discharge and follow-up.a very complex matrix

Examine the matrix with the staff to identifyprocedures that really provide value to the patient

Look at the non-value-added steps and try to

eliminate them with a different function,technological improvement, or change in process



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Transform the Lean VSM to an architecturalprogram with physical spaces that support andenhance this new lean approach to healthcare

delivery: When you design around lean concepts, you design a

safer environment

The leaner, safer, more cost-effective healthcare

environment incorporates a decentralized integratedservice delivery system



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Orient services around the patient instead of requiringthe patient to travel to the service:

Point-of-care testing

Identical single bed rooms: everything is always located inthe same place to eliminate the possibility of staff error.

Each patient room is its own work cell:

Staff completes charting, dispenses medications, andrestocks supplies within the room

The design allows for collaborative staff teaming: Team members move from patient to patient

Supplies are regularly deployed to within two feet of staff



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Adaptable-Acquity Single-

Bed RoomsResults: Lower nosocomial infection rates

Fewer patient transfers and associated medical errors

Less noise Better patient privacy and confidentiality

Better communication from staff to patients and frompatients to staff

Superior accommodation of family Higher patient satisfaction with overall quality of care.

Ulrich and Zimring, Sept 2004


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Improve Ventilation

Improved filters, high-efficiency particulateair (HEPA) and others

Appropriate pressurization Special vigilance during construction

Results:

Decreases acquired hospital infectionsUlrich and Zimring, Sept 2004


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Improve Lighting and View

Natural lighting, full-spectrum lighting, andviews of nature:

Results: Decreased length of stay

Decreased depression

Better emotional well-being

Improved sleep and circadian rhythm Decreased need for pain medication



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Reduce Noise Levels to 35dB

Single-bed rooms

Install high-performance sound-absorbingceilings tiles and flooring

Use noiseless paging Locate alarms outside patient rooms

Results: reduce stress (decreased BP and HR)

improve sleep

Improve patient satisfactionUlrich and Zimring, Sept 2004


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Develop Way Finding Systems

Develop way finding systems that allowusers, particularly outpatients and

visitors, to find their way efficiently andwith little stress

Results: Improves patient and visitor satisfaction

Increases staff efficiencyUlrich and Zimring, Sept 2004


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Re-design Nurses Stations

Reduce staff walking and fatigue Increase patient care time Support staff activities:

Medication supply close at hand Communication Charting Respite from stress

Results: Improved staff and patient satisfaction Decrease medical errors



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Impacts of design elements

on patient safety Air quality directly impacts nosocomial infection

rates, as fungal load in the air is linked tohumidity and malfunction of the ventilation

systems Private patient rooms decrease the risk of

patients acquiring an infection when comparedto the risk in double occupancy rooms

Improved lighting conditions decrease the risk ofmedication errors

Decreased noise levels cause decreased patientdisruptions and decreased length of stay

(Joseph, 2007).


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Impacts of design elements on

staff working conditions High noise levels are linked to increased rates of fatigue

and burnout among nurses

Unnecessary walking contributes to nurse fatigue and

reduces patient care time: the average nurse spends30% of the working shift walking

Easily accessible sinks and a high sink-to-bed ratioincreases rates of hand washing among clinical staff

(Joseph, 2007).

Ceiling and portable lifts decrease the number of injuriesassociated with patient lifting and handling

(Joseph, 2006).


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Patient-Centered Lean

Design Results Sutter Health, Elk Grove, California

Decreased staffing by 40%

Decreased patient wait times by 50%

Decreased building square footage by 30% Decreased Energy Consumption by 25%

Virtua Health, Voorhees, New Jersey Increased patient safety

Increased time staff spent on patient care

Saint Joseph Community Hospital, West BendWisconsin Became one of the most patient-safe hospitals in the country.



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Evidence Based Design Results

PeaceHealth Organization, Eugene, OR

Installed ceiling lifts and booms in patient rooms in twounits (ICU and Neurology) of its existing facility 2006

Virtually eliminated staff injuries caused from patienthandling

Decreased cost of staff injuries caused from patienthandling by 99%

Applying this data "house wide," they estimate that the

$1.64 million cost that they will spend making all 306patient rooms in their new facility lift ready will be paidback in approximately 1.88 years.

www.healthdesign.org/research/pebble/data.php


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Parrish Medical Center, Titusville, FL

New hospital 2002.

Access to natural light, improved airflow,separation of public/patient transport areas, and"homelike" patient room design.

Positively affected the quality of staff work-life

and help them provide care more effectively. Staff turnover decreased from 22% to 13%



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Evidence Based Design ResultsSt. Alphonsus Regional Medical Center, Boise, ID

Renovated a nursing unit in 2003 to test out the designmethodology it planed to use on a larger project

Larger private rooms, added carpet to hallways, putacoustical tiles on walls and ceilings, and relocatedmachinery and nurse charting away from patients

Quality of sleep improved from 4.9 to 7.3 (on a scale of0-10)

Patient satisfaction scores improved compared to a priorthree-month period.www.healthdesign.org/research/pebble/data.php


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Bronson Methodist Hospital, Kalamazoo, MI

New out- and inpatient pavilions in 2000

Private rooms, location of sinks, and air inflow design

11% decline in overall nosocomial infection rates. Decrease in patient transfers

Nursing turnover rates are down to 4.7%.

Occupancy rate has risen to 87%.

Overall patient satisfaction increased to 96.7%.

Market share has increased.

Employee satisfaction has improved.www.healthdesign.org/research/pebble/data.php


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Evidence Based Design ResultsMethodist Hospital / Clarian Health Partners, Indianapolis, IN

New Comprehensive Cardiac Critical Care 1999

Acuity-adaptable rooms, patient room layout, equipmentintegration

Decentralized design to allow for better patientobservation

Patient transfers down 90%

Patient falls are down 67%

Medication errors reduced 70% Unit design has helped reduce the caregiver workload

index, resulting in improvements in nursing efficiencywww.healthdesign.org/research/pebble/data.php


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Evidence Based Design ResultsBarbara Ann Karmanos Cancer Institute, Detroit, MI

Two inpatient units opened 1999 and 2000 Increased space in medication room, location of

medication room, organization of medical supplies,

standardized visual cues, and acoustical panels todecrease noise levels. Better visualization of patients due to angle of doorway,

improved lighting, and room layout. 30% reduction in medical errors

6% reduction in patient falls Patient satisfaction rose 18%. Nurse attrition rate fell from 23% to 3.8%.



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Results of new 100 bed community

hospital occupied 2003 Private, single-patient rooms, 225 sq. ft

Family area with futon

Nurse workstation alcove

Ceiling-mounted lifts in every room

Consistent lighting Dust-resistant blinds

Ergonomics in Hospital Design. The Advisory Board, (June2008)


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hospital occupied 2003-cont. Hands-free faucets

Humidity monitors

Rubber flooring Same-handed rooms

Results:

Quieter noise levels Reduced severity (but not #) of patient falls



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hospital occupied 2003-cont. Going into the new facility, Staff Satisfaction was

very high

One year after moving into the new facility, StaffSatisfaction was at an all time low as wasPatient Satisfaction

Currently, three years out, both Patient and StaffSatisfaction are increasing steadily each year asemployees become more accustomed to thenew design and the quality of care improves



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Hospital of the Future

Capacity Considerations:

Be sure of the need to expand

Use the impact of technology and practice changes

as well as demographics to project facility needs Anticipate the downstream impact of expansions; ED

Expansion on CT, ICU, and Med Surg

Provide for Interventional Flexibility: shelled in space

and pre-wired expansion capability to accommodatefuture changes in volume, mix, and technologyHospital of the Future, The Advisory Board, (2007)


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Space Planning:

Private rooms are the standard of care

Facility specialization is the enemy of efficiency and

flexibility. Strive to create general purpose ORs,ICUs, ED rooms, and Inpatient rooms.

Move support functions to non-hospital grade space

Consider moving non-acute clinical functions outside

the hospital walls.Hospital of the Future, The Advisory Board, (2007)


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Space Planning continued:

Design modified acuity-adaptable rooms that offerflexibility and decreased transfers

Preferable to the zero-transfer model (universal room model) Continue to use the ICU: Combine Med-Surg with PCU to

make the modified acuity-adaptable unit;

Up-skill the Med-Surg nurses to Acuity-Specialtynurses

Hospital of the Future, The Advisory Board, (2007)


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Design Elements: Space agility should be a top priority: to be able to

repurpose space to accommodate fluctuatingdemand, especially in departments with volatilevolumes

There is no right answer for inpatient unitconfiguration: many options exist and none is idealfrom every vantage point

Use semi-decentralized nursing stations to bringnurses closer to patients but allow peer interactionswith use of a small centralized area.



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Design Elements continued:

Encourage shared prep and recovery spaces in theoperating room area

Place interventional and surgical rooms on the samefloor to provide versatility to accommodate futurechanges in the mix of those volumes



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Four Worthy Design Principles

1. Semi-decentralized nursing stations: Small central station for interdisciplinary caregiver

communication with dispersed work stations fornursing documentation

2. Room Design Standardization: Single patient rooms

Sink by the door: same place for every room

Consistent supply storage: same place, same

drawer in every room Mirrored headwalls: standard gases and alarms in

same location on both sides of bedHospital of the Future, The Advisory Board, (2007)


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Four Worthy Design Principles

3. Ample In-room Family Space:

In-room Sleeping Accommodations: 40 sq ftfamily zone concept (Kaiser Permanente)

4. Accommodations for Obese Patients: Wider break-away doorway (61 doors)

Floor mounted toilets

Built-up shower stall to allow for wheel-chair access

Ceiling Lifts (800 lb capacity)



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Unit Configuration

Equipment service center:

Located in non-critical off-unit space

Manned by equipment techs

Receive nurse orders by phone and deliver to unitwithin 15 minutes

Round twice per shift for soiled equipment.



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Technology Needs

Build Flexible IT Infrastructure:

Over-wire the walls

Seamless wireless signal coverage is

essential Facility-wide RFID infrastructure need to track

objects

Build Technology Closets throughout the

hospital 5X8 up to 10X10 with tempmonitoring



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Use Flexible Design to allow

Future Change Concentrate on robust vertical and horizontal circulation

routes Recognize the importance of integrated work flows

between diagnostics and treatment Regard waiting as an educational opportunity Use technology to provide information to patients and

staff to support a speedy journey through treatment The overall layout needs to promote patient safety,

create the best working environment and recognize theunique needs of patients



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Top 10 List of Evidence

Based Design Features Single patient rooms Installing HEPA filters Providing access to nature

Installing ceiling lifts Installing sound-absorbing ceiling tiles Family areas within patient care spaces Providing access to sunlight Promoting the use of visible and accessible hand-

washing dispensers Promote visual access and accessibility to patients Providing areas of respite for staff

Center for Advanced Healing, Saint Alphonsus Regional MedicalCenter, Boise, Idaho 2008


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Key messages

Lean thinking needs to engage decision makers,clinical staff, managers, health planners, and designers

Need to move from isolated good practice to wholesystems pathways and system reform

Sharing information about good practice is urgentlyneeded

The potential for technology to assist needs to be furtherdeveloped

The implications of system redesign for the design of thephysical environment needs to be better understood

Both clinical and design staff could benefit from training


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References

Hagood, Charles, leanhealthcareexchange.com, Anita L. Tucker and Steven J. Spear, Operational Failures and

Interruptions in Hospital Nursing, Health Research and EducationalTrust, 2006, pp. 1-20.

Rutherford, P, Value Added Care Process, IHI presentation, Feb 2008 Spiering, K. FacilityManagement.com, (Oct 7, 2008) Ulrich and Zimring, Designing the 21st Century Hospital Project, The

Center for Health Design, Sept 2004

Joseph, A. Current Opinions in Critical Care. (2007) Joseph, A. Healthcare Design. (March 2006 www.healthdesign.org/research/pebble/data.php Ergonomics in Hospital Design. The Advisory Board, (June 2008)

Hospital of the Future, The Advisory Board, (2007) Center for Advanced Healing, Saint Alphonsus Regional Medical

Center, Boise, Idaho 2008


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Useful Web Sites

Advisory Boardwww.advisory.com AIA-Institute of Architects-www.aia.org Building Design and Construction- www.bdcmagazine.com Buildingwww.building.com The Center for Advanced Healing--

www

.saintalphonsus.org/CenterforAdvancedHealing.html The Center for Health Design--www.healthdesign.org Pebble Project--www.healthdesign.org/research/pebble/data.php IHIwww.ihi.org Contractwww.contractmagazine.com Facility Managementwww.facilitymanagement.com Health Affairswww.healthaffairs.com Health Facilities Managementwww.hfmmagazine.com Modern Healthcarewww.modernhealthcare.com Wall Street Journalwww.wsj.com


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Thank You

Questions?

Documents

C2 - Planning a new bed towerLean Healthcare Facility Design 11-18-08