using evidence-based design to reduce risk

7/30/2019 Using Evidence-Based Design to reduce risk

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Using Evidence-Based Design to

Increase Quality and Reduce Risk


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Six QuestionsBoards & CEOs must ask

1. Urgency

2. Appropriateness

3. Cost4. Financial impact

5. Sources of funds

6. Decreasing risk

Source: Blair Sadler


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Lois J. Zimring, Ph.D.

1923-2005


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Hospitals Are Dangerous

44,000-95,000 die each year due topreventable medical errors

IOM, 1999

2,000,000 Hospital-acquired infections a

year in U.S.; 88,000 die IOM, 2000

20% Nursing turnover

Nurses average 47+ years oldRWJF, 2005

Infections are more serious:22% of staph infection were MRSA in 199260% in 2005;

70%-90% of patients carrying MRSA arenever identified

NY Times 2005


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The Role of the Physical Environment

1. More evidence than expected: 700+rigorous studies

2. Many designs make hospitals morestressful & riskier for patients,families & staff.

3. A LOT of good evidence is available

Full report:www.healthdesign.org/research/reports


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The State of the Science

Staff effectiveness, stress, fatigue

Bedside computer 7Air quality 65

Design/POE/Work Flow 29Others 8

Patient Safety

Falls 30Infection 118Error 13+Others 18


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Increasing Safety

Clarian Methodist Hospital, Indianapolis:BSA LifeStructures

Transfers reduced 90%

Medication errors reduced 67%

Acuity-adaptable coronary critical care room


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Actual savings after ceiling lifts are

installed and used.

Unit DirectCost

#Injuries

Avgdirectcost perinjury

Avgindirectcost(2x)

TotalCost oneinjury

Avg #injuriesper year

TotalAnnualCost

Neuro $ 43,728 6 (2 yrs) $ 7288 $14,576 $21,864 3 $ 54,660

ICU $ 0 0 (2 yrs) $ 0. $ 0 $ 0 0 $ 0

subtotal $ 43,728 6 (2 yrs) $ 7288 $ 14,576 $ 21,864 3 $

54,660

PeaceHealth Riverbend, OR

Cost for 234 lifts and 75 lift-ready rooms: $1.6MPayback: 2.5 years


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Lighting

22% feweranalgesics

20% lower drug

costs Less pain, stress

Walch et al (2005)

Patients exposed to46% more naturalsunlight (lux/hours):

Sunlight affects analgesic use


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Lighting

Women stayed one dayless in sunnier room(2.3 v 3.3 days)

Death rate was 70%higher in dull rooms(39/335 v 21/293)

Patients in a CardiacIntensive Care Unit

Sunlight affects length of stay anddeath rate

Source: Beauchemin & Hays (1998)


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State of the Evidence

{ A large and growing bodyof evidence

{

Scattered and idiosyncratic{ Limited infrastructure for

research, translation and

application


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The Role of the Physical Environment

Evidence-Based Design is theconscientious, explicit and

judicious use of current bestevidence in making planning anddesign decisions that advance theneeds of patients, staff, families

and organizations.


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Design Driver Design Responses HypothesizedOutcomes

Support moreprocedures atthe bedside

Larger variablepatient rooms

Overhead booms

Improvedergonomics

Increased power,cabling, storage

Reduced patient transfercomplications and costs

Fewer errors

Shorter stays More time spent by ICU

staff in the ICU area

Design Drivers, Design Responses,Outcomes


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Design Drivers, Design Responses and OutcomeMeasures

Fewer medical and medication

errorsLess litigationReduced self-extubationDecreased falls and injuriesrelated to patients leaving beds

Improved ceiling tiles

Carpet whereappropriateCharting nichesZoned caregiver zone

Reduce medical errors

and increase patientsafety

Improved handwashingcomplianceLower MRSA and nosocomialinfection rate

Numerous rubs andhandwashing stations

Reduce infection

Less patient transfercomplications and costsFewer errorsShorter staysMore time spent by ICU staffin the ICU area

Medical gas boomsLarger patient zoneImproved ergonomics

Support moreprocedures at thebedside

Greater satisfaction on PressGaney and Emory ICU surveyFewer complaints & litigation

Family zone in patientroomKids roomLockers & showersFamily quiet room

Support families


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Best Practices Analysis

8555656

1xLaundry

1xGarden Space

2xxShowers

5xxxxxAdjacent Restrooms

2xxLockers

2xxPrivate FamilyRooms

2xxQuiet Rooms

5xxxxxKitchenette

1xRefreshments

4xxxxConsultation Rooms

1xChildren's Space

7xxxxxxxFamily Waiting Area

2xxInside ICU

5xxxxxAdjacent to ICU

ArkansasHarrisClarianMayo-LittaMayo

St.Eliz.

St.Lukes

Features in Family Waiting Area


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Typological Analysis: Clustering

Clusters of 5 patientbeds with self-contained nursingstations

Clusters of 10 patientbeds


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Charrette:

EUH, GT, HKSJ uly 2005


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AFTER

BEFORE

Patient room Family waiting area Nurses station

Private

familyarea

Kids zone

Shower andlaundry for

family

Healing garden

Larger

Patientroom

Workstation


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New Floorplan

Privatefamilyarea

Shower andlaundry forfamily

Caregiverentry

Familyentry

Distributed nursesstations designed tosupport specificactivities

Healinggarden

Workstation


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Center for Health Design

{

Non-profit research & advocacyorganization

{ Work began in 1988

{

Research, education, advocacy,support

http://healthdesign.org


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The Pebble Project


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Purpose

{

Create a ripple effect{ Provide examples

{ Establish a research model

{ Start a dialogue


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Partners

{

40 active provider partners{ 2 corporate partners

{ Various project types

{ Different stages of design


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Pebble PartnersProviders

{ Childrens Hospital & Health Center, San Diego, CA

{ Bronson Methodist Hospital, Kalamazoo, MI

{ Froedtert Hospital, Milwaukee, WI

{ Weill Cornell, New York, N.Y.

{ Parrish Medical Center, Titusville, FL

{ St. Alphonsus Regional Medical Center, Boise, ID{ Yavapai Regional Medical Center, Prescott, AZ

{ Scott & White Memorial Hospital, Temple, TX

{ Sitrin Health Care Center, New Hartford, N.Y.

{

M.D. Anderson Cancer Center, Houston, TX{ PeaceHealth Oregon Region, Eugene, OR

{ Columbia St. Marys, Milwaukee, WI

{ Affinity Health System, Appleton, WI


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Pebble PartnersProviders, contd

{ Banner Estrella Medical Center, Phoenix, AZ

{ Edward Hospital & Health Center, Naperville, IL

{ St. Elizabeths Hospital, Appleton, WI

{ Shawnee Mission Medical Center, Shawnee Mission, KS

{ St. Benedicts Family Medical Center, Jerome, ID

{ Community Mercy Health Partners, Springfield, OH{ Village Care of New York, New York, NY

{ St. Josephs Community Hospital, West Bend, WI

{ Dublin Methodist Hospital, Dublin, OH

{

Palomar Pomerado Health, Escondido, CA{ Provena St. Joseph Medical Center, Joliet, IL

{ SSM Healthcare, St. Louis, MO


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Pebble PartnersProviders, cont

{ Laguna Honda Hospital & Rehab Center, SanFrancisco, CA

{ Lake Hospital System, Painesville, OH

{ St. Josephs-Baptist Health Care, Tampa, FL

{ St. Lukes Episcopal Hospital, Houston, TX

{ Spectrum Health, Grand Rapids, MI

{ Lakeland Health, St. Joseph, MI

{ Virtua Health, Voorhees, NJ

{ Steelcase

{ Hill-Rom


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Bronson MethodistKalamazoo, MI

{

$181 million{ December 2000

{ $42 million less for new construction

Architecture & Interior

Design:Shepley Bulfinch Richardson

& Abbott


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Bronson MethodistAreas of Measurement

{ Turnover

{ Outcomes

{ Length of stay

{ Cost per unit of service

{ Waiting times

{ Satisfaction

{ Organizationalbehavior

{ Productivity


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Bronson MethodistSelected Data: Safety & Operations

{

11% decrease in infections{ $500,000 savings a year in transfers

{ Increased market share

{ 87% occupancy


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Bronson MethodistSelected Data: Nosocomial Infections

0.89%

0.80%

0.74%

0.76%

0.78%

0.80%

0.82%

0.84%

0.86%

0.88%

0.90%

Bronson Healthcare Group Total

Old Hospital New Hospital


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Bronson MethodistSelected Data: Market Share

5

10

15

20

25

30

1996 1997 1998 1999 2000 2001 2002 2003 2004 Jan-Apr2005

BronsonCompetitor 1Competitor 2Competitor 3


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Bronson MethodistSelected Data: Satisfaction

{

4.7% nurse turnover{ Increased employee satisfaction

{ 96.7% patient satisfaction


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Bronson MethodistSelected Data: RN Turnover

0%

5%

10%

15%

20%

1998 1999 2000 2001 2002 2003 2004 Q2 2005

BMH National Benchmark Best Practices National Benchmark

Source for National Benchmark: The Advisory BoardSource for Best Practices: ANCC


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Bronson MethodistSelected Data: Overall Turnover

0

5

10

15

20

25

2001 2002 2003 2004 Q2 2005

Bronson National Avg Best Practice


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Bronson MethodistSelected Data: Physician Satisfaction

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Good Place to

Practice Medicine

Quality of Nursing

Care

2003 Actual 2004 Target 2004 Actual


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Bronson MethodistSelected Data: Patient Satisfaction

Inpatient Experience Better Than Expected

30

35

40

45

50

1996 1997 1998 1999 2000 2001 2002 2003 2004


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Bronson MethodistSelected Data: Built Environment

{ Patient room features rated high

{ Positive correlation/key measures

{ Enables high quality of care


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Bronson MethodistSelected Data: Staff Productivity

{ RNs in GMU walk more

{ Design differences are plausibleexplanation


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Bronson MethodistPerformance Results


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St. AlphonsusSelected Data: Noise

Average Decibel Rate by Room

0.8000

0.8200

0.8400

0.8600

0.8800

0.9000

0.9200

0.9400

0.9600

0.9800

1.0000

Room

204

Room

205

Room

212

Room

524

Room

525

Room

539

Room

540

Room

532

80.1 - 85

75.1 - 8070.1-75

65.1- 70

60.1 - 65

55.1 - 60

51.7- 55

Less than 51.7


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St. AlphonsusSelected Data: Sleep Quality

Quality of Sleep After Several Nights'Experience on one of the Two Study Units

4.9

7.3

0

1

23

4

5

6

7

8

9

10

2E 5S

Scale

(0-10)


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St. AlphonsusSelected Data: Satisfaction

3 Month Comparison of Patient Satisfaction Scores: 2E/S5

* * * *

** *

**

*

* * *

0

10

20

30

40

50

60

70

80

Would

Rec

omm

end

Coordin

atio

nof

Care

Spiri

tual/Em

otNeeds

Prom

ptRegis

tration

Cle

anlin

essof

facility

Cle

anlin

essof

Room

Court

.FoodStaff

Expl

aine

dDiet

Nur

sesLi

sten

ed

Con

cern

Com

f/Priv

Tim

elyR

espo

nse

Respo

nseto

CallLt

MD

Courte

sy

MD

Ans

Que

stio

ns

Arr

anged

othe

rcar

e

Would

Return

Top

BoxP

ercent

2E, n=80

S5, n=43


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Palomar Pomerado Health &The Center for Health Design

A Collaboration


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The Fable Hospital


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The Fable Hospital

How much does a better building cost?

To answer that, we inventedThe Fable Hospital.

Based on Pebbles measured experienceusingEvidence Based Design (EBD).


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Unusual Culture

{ Obsessed with quality and safety

{ Driven by values

{ Patient focused

{ Family friendly

{ A good corporate citizen

{ Determined to be eco-sensitive

{ Willing to benchmark

{ Want to be held accountable


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Design Features

{ Oversized, windowed, single rooms

{ Variable acuity rooms

{ Decentralized, barrier-freenursing stations

{ Computerized order entry,bar code, PDAs

{ Additional hand-washing facilities

{ HEPA filters


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Design Features, contd

{ Double-door bathroom access

{ Healing art, music, and gardens

{ Consultation spaces

{

Patient education center{ Staff support facilities


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The Fable Hospital

{ 300-bed regional medical center

{ Urban site

{ $240 M replacement facility

{

Values: quality, safety, patients,families, staff, cost, value,community responsibility


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The Fable HospitalDetailed Construction Cost Estimates

Example

+ $12 Million(5% of project cost)


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The Fable HospitalSavings & Revenue

Example


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The Fable Hospital

Cost avoidance savings alone, ifinvested at 3% for 30 years, wouldpay the capital costs of the hospitalmany times over.

H ow m a n y o f o u r 4 3 m i l l i o n

u n i n s u r e d c i t i z e n s w o u l d t h i s

c o v e r ?


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www.healthdesign.org

www.ache.org

Fall 2004 Issue


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Critical Role of TimeYou can never start too soon!

TwoD

egreeC

orrect

ion

CurrentDevelopment

Course

X Years prior to Construction

Time

Construction

Financing

$s

The

Gap

The Process Perspective


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The Process Perspective

Process is the key to success

Better processes make better buildings Many process mapsin the industry

Good but not perfect

Role of client is crucial Be the best client you can be

Crucial phase: Project Planning (PP)

Our target: A PP guide for clients and theirproject partners

Process timeline


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ocess e e

PP VECrucial phases: Commissioning

High level process maps


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g p p


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An process example (DoD)

Health Facilities Planning Agency (HFPA)Pre-Planning Process

Health Facilities Planning Agency (HFPA)


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Master Planning

Building a road map to provide guidance towards afinal solution

Not static, fluid document

Revised every 3-5 yrs (or when major change occurs)

Creates better requirements, thus better projects

Project Books

Project Specific MIL-Handbook 1191 criteria

Pre-Planning Process


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What can we do better?


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More client control upstreamPush choice of solutions downstream

How?

Better capture of client needsBetter control over the process (PP)

The Process Planning Guide


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An overview of trends in project management,with emphasis on empowering the client in thePP phase

Strengths and weaknesses Best practices, milestones, document formats

Highlights of performance based building ingeneral

How can the EBD knowledge base be infused What do current team technologies offer?

Communities, portals, etc

What do current KM technologies offer? Maximize the ROI of the EBD knowledge base Populate the PP phase with structured tools

Outcomes of recent academic research


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Wh t Y Mi ht D N


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What You Might Do Now

{ Create a Project Plan

{ Clinic Models

{ Create design drivers

{ Start a TransformationalCollaboration process

{ Create RFQs


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How can we best support your

project?

using evidence-based design to reduce risk

Documents