Agency for Healthcare Research and Quality Advancing Excellence in Health Care Safety by Design Initiatives at AHRQ Kerm Henriksen Sandi Isaacson Catherine Hinz

Advancing Excellence in Health Care Three Objectives Describe AHRQ’s involvement in safety by design Describe AHRQ’s involvement in safety by design Provide some examples of safety by design in the hospital environment Provide some examples of safety by design in the hospital environment Show DVD on how design of the hospital environment can have a a transforming effect Show DVD on how design of the hospital environment can have a a transforming effect Evelina Children’s Hospital South London

Advancing Excellence in Health Care Crossing the Quality Chasm: Designing in Safety and Quality Current $250 billion building boom in US in new hospital construction Current $250 billion building boom in US in new hospital construction Design has a direct impact on patients, families & providers Design has a direct impact on patients, families & providers Emerging evidence base from past two decades affirms that safety & quality can be designed into construction of new facilities. Emerging evidence base from past two decades affirms that safety & quality can be designed into construction of new facilities. Ulrich et al First we shape our buildings, and then our buildings shape us. - Winston Churchill

Advancing Excellence in Health Care AHRQ’s Involvement in Safety by Design Informal cross-center workgroup Informal cross-center workgroup Georgia Tech Small Conference Grant Georgia Tech Small Conference Grant HIT grant to St. Joseph’s Community Hospital HIT grant to St. Joseph’s Community Hospital Mistake-Proofing with Dr. John Grout Mistake-Proofing with Dr. John Grout QSHC Safety by Design Supplement QSHC Safety by Design Supplement Blueprint for Change Podcast with Dr. Clancy Blueprint for Change Podcast with Dr. Clancy AHRQ Presentation – Role of Physical Environment AHRQ Presentation – Role of Physical Environment Transforming Hospitals by Design DVD Transforming Hospitals by Design DVD Articles in press Articles in press

Advancing Excellence in Health Care Quality & Safety in Health Care: Safety by Design Rather than continuing to try to measure the width and depth of the quality chasm..... how does one actually begin to close the quality chasm? One way to think about the problem is as a design challenge rather than as a quality improvement challenge. It is time to move from reactive measurement to a more proactive use of proven design methods, and to involve a number of professions outside health care so that we can design out system failure and design in quality of care. Battles, Dec. 2006

Advancing Excellence in Health Care Quality & Safety in Health Care: Safety by Design Supplement includes articles on design of: High reliability organizations (HROs) Clinical microsystems Training initiatives Clinical work processes Healthcare worker performance System latent conditions Healthcare software usability

Advancing Excellence in Health Care No Environment is Neutral The design of facilities, work processes, technology, and organizations impact one another as well as providers patients, and their families. Either positively or negatively, the design will exert its impact.

Advancing Excellence in Health Care Evidence-Based Design (EBD) In parallel with evidence-based medicine, EBD uses the best available information from credible research In parallel with evidence-based medicine, EBD uses the best available information from credible research Utilizes findings & expertise from architecture, health design, clinical work processes, HIT, human factors & ergonomics, industrial & system engineering, environmental psychology & organizational theory Utilizes findings & expertise from architecture, health design, clinical work processes, HIT, human factors & ergonomics, industrial & system engineering, environmental psychology & organizational theory Employs function & task analyses, failure mode & effects analyses, learning labs for design teams, mock-ups, modeling, simulations, iterative testing & evaluation, usability testing, and operational try-outs in addition to experimental designs Employs function & task analyses, failure mode & effects analyses, learning labs for design teams, mock-ups, modeling, simulations, iterative testing & evaluation, usability testing, and operational try-outs in addition to experimental designs

Advancing Excellence in Health Care Evidence Based Design (EBD) Build Single Patient Rooms Build Single Patient Rooms Reduce Noise Reduce Noise Incorporate Nature Incorporate Nature Improve Air Quality Improve Air Quality Encourage Hand Hygiene Encourage Hand Hygiene Improve Way-finding Improve Way-finding Reduce Walking Distance Reduce Walking Distance

Advancing Excellence in Health Care Small Conference Grant to Georgia Tech Healthcare Environments Research Summit Summit focused on: Summit focused on: 1. High priority research directions 2. Research to application pipelines 3. Call to action – near & mid-term goals

Advancing Excellence in Health Care Design Principles at St. Joseph’s Community Hospital in West Bend, WI Patient to Staff Visibility Patient to Staff Visibility Standardization Standardization New Technology New Technology Noise Reduction Noise Reduction Quick Access to Information Quick Access to Information Involve Patients with Care Involve Patients with Care Scalability & Adaptability Scalability & Adaptability Minimize Fatigue Minimize Fatigue Design for Precarious Events Design for Precarious Events Minimize Patient Transfers/Handoffs Minimize Patient Transfers/Handoffs

Advancing Excellence in Health Care Evidence Based Design DVD Transforming Hospitals: Three Case Studies DVD examines three hospitals that have incorporated evidence- based design in renovations or initial construction Release Date: October 2007

Advancing Excellence in Health Care Physical Environment Facility design & layout Facility design & layout Lighting Lighting Noise Noise Temperature & humidity Temperature & humidity Vibration Vibration Air flow Air flow Contamination & pollutants Contamination & pollutants Workplace hazards Workplace hazards Safety features Safety features Security features Security features Signage & way-finding Signage & way-finding Workstation ergonomics Workstation ergonomics Special user group requirements & equipment Special user group requirements & equipment In adopting a systems perspective, research needs to examine how the physical environment interacts with people, work processes, tools/technology, and organizations to realize improved processes & outcomes.

Advancing Excellence in Health Care Acuity Adaptable Rooms Acuity Adaptable Rooms Bringing different levels of acute care to the patient Operationalizes concept of patient- centeredness Operationalizes concept of patient- centeredness ICU capable headwall ICU capable headwall Sink for hand hygiene Sink for hand hygiene Adjacent nurse work station Adjacent nurse work station LCD Window Observation LCD Window Observation Flat Screen Monitoring Flat Screen Monitoring Family Accommodation Family Accommodation Patient Education Patient Education Three-year post-intervention data show considerable reduction in transfers (90%), medical errors (70%), and number of falls Three-year post-intervention data show considerable reduction in transfers (90%), medical errors (70%), and number of falls Hendrich, Fay, Sorrells, 2004

Advancing Excellence in Health Care Use of Natural & Full Spectrum Lighting Helps reduce depression Helps reduce depression Restores disrupted circadian rhythms Restores disrupted circadian rhythms Less perceived stress, pain, use of analgesic medication Less perceived stress, pain, use of analgesic medication Shorter length of stay Shorter length of stay Ulrich, Quan, Zimring, Joseph & Choundhary, 2004

Advancing Excellence in Health Care Reduce Noise Levels Install sound-absorbing ceiling tiles/wall panels Install sound-absorbing ceiling tiles/wall panels Treat hallways to reduce equipment sounds Treat hallways to reduce equipment sounds Decentralize nursing stations Decentralize nursing stations Eliminate overhead paging systems Eliminate overhead paging systems Evaluate alarm appropriateness Evaluate alarm appropriateness Mask noxious sounds with pleasant sounds Mask noxious sounds with pleasant sounds Establish quiet zones & interrupt-free zones Establish quiet zones & interrupt-free zones Build single-patient rooms Build single-patient rooms

Advancing Excellence in Health Care Wayfinding Wayfinding “aah...which way do I go..... I’ll just sit here.” Are entrances and exits obvious? Are entrances and exits obvious? Are directional signs used appropriately at intersections? Are directional signs used appropriately at intersections? Is the visual environment free of clutter? Is the visual environment free of clutter? Do icons clearly convey intended meaning? Do icons clearly convey intended meaning? Do “you are here” maps also show where users want to go? Do “you are here” maps also show where users want to go? Are floor and room number schemes easy to understand? Are floor and room number schemes easy to understand? Is terminology used on signage plain and simple? Is terminology used on signage plain and simple?

Advancing Excellence in Health Care Expected Benefits Using EBD Safer environment for patients & providers Safer environment for patients & providers Improved work processes & flow Improved work processes & flow Greater standardization for efficiency Greater standardization for efficiency Electronic access to medical records Electronic access to medical records Improved hand hygiene Improved hand hygiene Single bed rooms to reduce HAI Single bed rooms to reduce HAI Better air filtration systems Better air filtration systems Mistake proofing for devices Mistake proofing for devices Improved patient lifts & handling Improved patient lifts & handling Kinder working conditions Kinder working conditions Improved transitions of care Improved transitions of care Prevention of falls Prevention of falls Shorter wait times Shorter wait times Adjustable lighting Adjustable lighting Noise reduction Noise reduction Improved signage & way-finding Improved signage & way-finding Shorter healing & recovery time Shorter healing & recovery time Better family/ visitor accommodation Better family/ visitor accommodation

Advancing Excellence in Health Care A New Way of Thinking for Health Services Researchers Focuses on quality & safety before hospital is built rather than later as an after-thought; eliminates adoption problem Focuses on quality & safety before hospital is built rather than later as an after-thought; eliminates adoption problem Achieves maximum leverage by informing capitol budget decision- making rather than limited operating budgets Achieves maximum leverage by informing capitol budget decision- making rather than limited operating budgets Reaps daily savings in terms of safety, effectiveness & efficiency that accrue for decades & decades Reaps daily savings in terms of safety, effectiveness & efficiency that accrue for decades & decades Hospital building boom is on national radar screen; now is the time to be involved. Hospital building boom is on national radar screen; now is the time to be involved.

Advancing Excellence in Health Care Evidence Based Design Sources The Role of the Physical Environment in the Hospital of the 21 st Century: A Once-in-a-Lifetime Opportunity (Center for Health Design) Improving Healthcare with Better Building Design (Center for Health Design) Planning, Design, and Construction of Health Care Facilities (Joint Commission Resources) Guidelines for Design and Construction of Hospital and Healthcare Facilities (The American Institute for Architects) Enhancing the Traditional Hospital Design Process: A Focus on Patient Safety (Joint Commission Journal on Quality and Safety) Play video

Advancing Excellence in Health Care