C2 - Planning a new bed towerLean Healthcare Facility Design 11-18-08
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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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Patient-Centered Lean Design
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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Patient-Centered Lean Design
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
Spiering, K, FacilityManagement.com, October, 2008
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Patient-Centered Lean Design
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
Spiering, K, FacilityManagement.com, October, 2008
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Patient-Centered Lean Design
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
Spiering, K, FacilityManagement.com, October, 2008
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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
Ulrich and Zimring, Sept 2004
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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
Ulrich and Zimring, Sept 2004
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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.
Spiering, K, FacilityManagement.com, October, 2008
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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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Evidence Based Design Results
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%
www.healthdesign.org/research/pebble/data.php
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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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Evidence Based Design Results
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%.
www.healthdesign.org/research/pebble/data.php
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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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Results of new 100 bed community
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
Ergonomics in Hospital Design. The Advisory Board, (June2008)
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Results of new 100 bed community
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
Ergonomics in Hospital Design. The Advisory Board, (June2008)
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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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Hospital of the Future
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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Hospital of the Future
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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Hospital of the Future
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.
Hospital of the Future, The Advisory Board, (2007)
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Hospital of the Future
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
Hospital of the Future, The Advisory Board, (2007)
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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)
Hospital of the Future, The Advisory Board, (2007)
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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.
Hospital of the Future, The Advisory Board, (2007)
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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
Hospital of the Future, The Advisory Board, (2007)
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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
Hospital of the Future, The Advisory Board, (2007)
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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
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