hcd_2007_flexibility study

EVIDENCE BASED DESIGNEVIDENCE BASED DESIGNRESEARCH STUDIES

Defining the Design Characteristics of a

S f l Ad t blSuccessful AdaptableInpatient Unit

Debajyoti Pati, PhD, AIIATom E. Harvey Jr., AIA, MPH, FACHA

Acknowledgements/Credits

• AIA 2006 Research Grant• Herman Miller• Dr Carolyn Cason, UT Arlington School of Nursing• Parker Adventist Hospital Parker CO• Parker Adventist Hospital, Parker, CO• Clarian West Medical Center, Avon, IN• Laredo Medical Center, Laredo, TXLaredo Medical Center, Laredo, TX• McKay-Dee Hospital Center, Ogden, UT• Bon Secours St. Francis Hospital,Charleston, SC• St. Rose Dominican Hospital – Siena, Henderson,

NV

Learning objectives

• Understand the role of flexibility in promoting ffi i i ti tefficiency in patient care.

• Understand what ‘flexibility’ means from various stakeholders’ perspective on inpatient units.p p p

• Understand characteristics of the physical environment that impede or facilitate flexibility.

• Obt i d d t di f i ti t it• Obtain a deeper understanding of inpatient unitoperations, coordination between caregivers, and implications of such factors on the physical design.

Content

• Flexibility background• Information gap• Framework• Question• Question• Method• Flexibility meaningFlexibility meaning• Flexibility to Adapt• Flexibility to Convert• Flexibility to Expand• Conclusions

Flexibility background

• The architectural perspective:– Workplace and retail sectors: shearing layers

• Shell, services, scenery, set• Site, structure, skin, services, space plan, stuff

– Healthcare sector: systems• Open building paradigm

– Primary, secondary, tertiary • Spine concept

Information gap

• Hospital level flexibility concepts

• Very little information at inpatient unit level:Universal rooms– Universal rooms

– Distributed caregiver workstations

• Importance:– Changing demographics– Changing labor marker

Change unit operational model

g g– Changing technology– High volume investment on bed units

Question

• What does flexibility mean to different stakeholders?

• What physical design variables influence stakeholders’ flexibility?

• What designs elements promote or hinder flexibility?flexibility?

Framework

• Flexibility to adapt: accommodate change without change in environmentchange in environment

• Flexibility to convert: accommodate change after simple/inexpensive physical alteration

• Flexibility to expand: expand over time• Flexibility to expand: expand over time

Method

• SETTING– Six hospitals– Medical-surgical units

• SAMPLING– Purposive

M i i i bilit– Maximize variability

• DESIGNDESIGN– Exploratory– Qualitative

Method

• PARTICIPANTS– Nursing, RT, Materials

Management, EVS, Pharmacy, Dietary

• TOOLS– Semi-structuredSemi structured

interviews– Plan of inquiry– Content analysisContent analysis

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Parker Adventist Hospital

2004 100 36 Irregular Racetrack Primary 1:5 YesHospitalParker COClarian West Medical CenterAvon IN

2005 76 32 Square Racetrack Primary 1:4 Yes

Laredo Medical 1998 325 36 Pinwheel Racetrack Functional/ 1:8 NoCenterLaredo TX

Modular

McKay-Dee Hospital CenterOgden UT

2002 317 28 Triangle/ Rectangle

Racetrack Functional 1:5 No

Bon Secours St 1997 141 40 Square Radial Modified/ 1:5 NoBon Secours St.Francis HospitalCharleston SC

1997 141 40 Square Radial Modified/Modular

1:5 No

St Rose Dominican Hospital-SienaH d NV

1999 214 34 Other T-Shape Functional 1:6 Yes

Henderson NV

Parker AdventistFIGURE LEGENDM MedicationE EquipmentC Clean Supply/ UtilityS Soiled Supply/ UtilityS Soiled Supply/ UtilityN Nursing Station

Construction Completion 2004Total Bed 100SqFt per Bed 607Unit Size 36Unit Shape Irregular

Circulation Racetrack

Nursing Model Primary

Nurse:Patient Ratio 1:5U i l R YUniversal Room Yes

Clarian WestFIGURE LEGENDM MedicationE EquipmentC Clean Supply/ UtilityS Soiled Supply/ UtilityS Soiled Supply/ UtilityN Nursing Station

Construction Completion 2005Total Bed 76SqFt per Bed 700Unit Size 32Unit Shape Square


Nursing Model Primary

Nurse:Patient Ratio 1:4Universal Room Yes

Laredo Medical CenterFIGURE LEGENDM MedicationE EquipmentC Clean Supply/ UtilityS Soiled Supply/ UtilityS Soiled Supply/ UtilityN Nursing Station

Construction Completion 1998Total Bed 325SqFt per Bed 528Unit Size 36Unit Size 36Unit Shape Pinwheel


Nursing Model Functional/Modular

Nurse:Patient Ratio 1:8Universal Room No

McKay DeeFIGURE LEGENDM MedicationE EquipmentC Clean Supply/ UtilityS Soiled Supply/ UtilityS Soiled Supply/ UtilityN Nursing Station

Construction Completion 2002Total Bed 317SqFt per Bed 673Unit Size 28Unit Shape Triangle/

Rectangle


Nursing Model Functional


St Francis HospitalFIGURE LEGENDM MedicationE EquipmentC Clean Supply/ UtilityS Soiled Supply/ UtilityS Soiled Supply/ UtilityN Nursing Station

Construction Completion 1997Total Bed 141SqFt per Bed 520Unit Size 40Unit Shape SquareUnit Shape Square

Circulation Radial

Nursing Model Modified/ Modular


St Rose Dominican-SienaFIGURE LEGENDM MedicationE EquipmentC Clean Supply/ UtilityS Soiled Supply/ UtilityS Soiled Supply/ UtilityN Nursing Station

Construction Completion 1999Total Bed 214SqFt per Bed 541Unit Size 34Unit Shape OtherUnit Shape Other

Circulation T-Shape

Nursing Model Functional

Nurse:Patient Ratio 1:6Universal Room Yes

FINDINGS

Flexibility meaning

• Management– Ability to manipulate higher-level resources (staffing,

teaming) to address unique circumstances and uncertainties

• Direct caregiver– Ability to multi-task and multi-skill to optimize patient care,

maximize efficiency and address unique situations

• Non-nursing personnelo u s g pe so e– Ability to manipulate resources to effectively address

nursing management and direct care giver needs

FLEXIBILITY TO ADAPT

Peer lines-of-sight

• Operational issue • Implications– Helping hand,

mentoring, socialization, de-stressing

Aff t

– Simple shape units– Corner location of

caregiver workstation in t• Affects

– Nurse, respiratory therapist

support core– Back-stage corridors

linking caregiver workstations• Environmental

correlates– Caregiver work station,

workstations– Simple circulation

configurationg ,

corridor shape, corridor configuration

Peer lines-of-sight

Patient visibility

• Operational issue • Implications– Higher acuity, JCAHO

regulations, non-contiguous patients

Aff t

– Multiple caregiver work centers with proximal patient roomsU b t t d i htli• Affects

– Nurse, nursing administration,

i t th i t

– Unobstructed sightlineto patient rooms

– Outboard toilet locationrespiratory therapist

• Environmentalcorrelates– Caregiver workstation,

medication room, utility room

Patient visibility

Multiple division/zoning option

• Operational issue • Implications– Perceived barriers– Assignment problems

• Affects

– Stairwell and support spaces located at end of an array of patient rooms or inside theAffects

– Nurse, nursing administration,

• Environmental

rooms, or inside thesupport core

– Simple circulation configurationEnvironmental

correlates– Stairwell, support

spaces staff toilets

g

spaces, staff toilets

Multiple division/zoning option

MODIFIED CORNERS = PERCEIVE D BARRIER

Proximity of support

• Operational issue • Implications– Walking distance– Stress, fatigue

• Affects

– Simple shape, symmetrical units

– Distributed nursing tAffects

– Nurse, nursing administration,environmental services,

support spaces proximate to distributed caregiver workstations

– Decentralized room-dietary services, materials management, respiratory therapy

E i t l

– Decentralized room-side supply cabinets

• Environmentalcorrelates– Patient room, support

spaces

Proximity of support

Resilience to move services

• Operational issue • Implications– Long term census

fluctuation• Affects

– Standardized room– Standardized support

core– Nurse, nursing

administration• EnvironmentalEnvironmental

correlates– Standardization

Resilience to move services

Inter-unit movements

• Operational issue • Implications– Multi-unit caregiver

responsibility• Affects

– Communicating stair inside unit

– Proximal location of ti l i l ti– Nurse, environmental

services, dietary services, materials

t

vertical circulation core– Back corridor inter-unit

linkU b t t d h i t lmanagement,

pharmacy, respiratory therapy

• Environmental

– Unobstructed horizontalcirculation

• Environmentalcorrelates– Vertical circulation core,

unit proximity horizontalunit proximity, horizontalaccess

Inter-unit movements

Service expansion options

• Operational issue • Implications– Census fluctuations– Unit-service misfit

• Affects

– Visual or geographic cues to help unit subdivisionsB k id li kAffects

– Nurse, nursing administration

• Environmental

– Back corridor linksbetween adjacent units

Environmentalcorrelates– Unit size, unit

configuration unitconfiguration, unitadjacency

Service expansion optionsC

SOFT SPACE FOR SUPPORT CORESUPPORT CORE

EXPANSION/ SHARING

NNSERVICE SPREAD

INTO ADJOINING UNIT

N

FLEXIBILITY TO CONVERT

Adjustable support core

• Operational issue • Environmentall t– Supply and equipment

storage– Shape and size of

correlates– Cabinetry, support room

shape, support room si erooms

• Affects– Nurse, nursing

size• Implications

– Modular, movable administration,environmental services, dietary services, materials management

compartments or cart system for storage

– Minimize walls with MEP elementsmaterials management,

pharmacy, respiratory therapy

MEP elements

Adjustable support core

FLEXIBILITY TO EXPAND

Expandable support core

• Operational issue • Environmentall t– Operational changes

over time• Affects

correlates– Adjacent functions

• Implications– Nurse, nursing

administration,environmental services, di t i

p– Soft program adjacent

spaces

dietary services,materials management,pharmacy, respiratory therapypy

Expandable support coreC

SOFT SPACE FOR SUPPORT CORESUPPORT CORE

EXPANSION/ SHARING

NN

N

We thank you for your attention!

Brief bibliography

Chefurka, T., Nesdoly, F. and Christie, J. , 2006, “Concepts in Flexibility in Healthcare Facility Planning, Design, and Construction”. The AcademyHealthcare Facility Planning, Design, and Construction . The AcademyJournal Online, http://www.aia.org/aah/journal, pp. 34-43.

Hamilton, K. 2000 - Design for Flexibility in Critical Care. Proceedings of ICU 2010, Center for Health Systems and Design, Texas A&M University, April.

Hendrich A Fay J Sorrels A K 2004 Effects of Acuity-Adaptable Rooms onHendrich, A., Fay, J., Sorrels, A.K., 2004. Effects of Acuity Adaptable Rooms onFlow of Patients and Delivery of Care. American Journal of Critical Care, Vol. 13 /1, pp.35-45.

Kendall, S. H., 2004, Open Building: A New Paradigm in Hospital Architecture. AIA Academy Journal, 7th Edition, pp.22-27.y , , pp

Ulrich, R., Zimring, C., Quan, X., and Joseph, A., 2004, “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity”. The Center for Health Design, http://www.healthdesign.org/ research/reports/pdfs/role _physical_env.pdf

Varawalla, H. 2004, “Designing for Flexibility Building in order and direction for growth and change”. Express Healthcare Management , August 15-30, 2006, http://www.expresshealthcaremgmt.com/ 20040831/architecture01.shtml

Contact information

Debajyoti Pati, PhD, AIIADirector of Research, HKS Architects,

Tom E Harvey Jr, AIA, FACHA, MPHPrincipal, HKS Architects,

1919 McKinney Avenue, Dallas, TX, [email protected]

1919 McKinney Avenue, Dallas, TX,[email protected]