whd_2012_patient unit comparison study
TRANSCRIPT
Retaining the Caring Presence and
Healing Touch in New Generation
Asian Hospitals: Learning from the
American Experiment
8TH DESIGN & HEALTH 2012 KUALA LUMPUR
Agenda
Introduction – Decentralization
Study Objectives
Context – MD Anderson Cancer Center
Data Collection
Findings
Summary
INTRODUCTION
Drivers and Design Impacts
Single patient rooms
Larger footprints
Proximity challenges
Decentralization
Decentralization
Use of technology
Healing presence/time at the bedside
Teamwork
Hypothesized Impacts
Patient focused
More time with patient
Improved efficiencies
Reduced non-productive time
Reduced walking distance
Collaboration, teamwork and mentoring?
Stress reduction?
Chaos, noise
Socialization
Productivity improvement
OBJECTIVE
Objective
To examine the impact of decentralization on operational
efficiency and teamwork – drivers of the healing touch
and caring presence.
Goals of the Study for MD Anderson
Assist in adaptation to the new unit design
Identify new processes for
Communication
Collaboration
Task completion
Larger unit footprint
Seek opportunities
Education and training
Modify design elements
STUDY CONTEXT
Texas Medical Center (42 member institutions, 13 major hospitals with 66,000 employees)
A healthcare component of the University of Texas
Founded in 1941, M. D. Anderson has grown to over 18,000 faculty and staff
More than $2.2 billion annual revenue
M.D. Anderson Cancer Center
M.D. Anderson Cancer Center Growth
1998 – 1999
20% growth in patients
1999 – 2008
80% growth in patients
75% increase in
employees
115% increase in
research revenue
2012 Projections
50% growth in patients
from 2006
Then and Now
Typical Nursing
Floor
(4) 13-bed Units
All Private Rooms
Central Nurse
Station
Racetrack Design
Service & Public
Elev.
Albert B. and Margaret M. Alkek Hospital
THEN
Central Nursing
Station
Albert B. and Margaret M. Alkek Hospital
THEN
Unit Configuration
Centralized work
concept
Open medication
prep areas
Family waiting areas
small/lacking
Wayfinding
challenges
THEN
Key Design Goals and Objectives
The new Alkek patient units were designed reviewing
current evidence-based concepts in a manner that:
Promotes patient and family centered care
Maximizes efficiency of work effort for all members
of the care team
Includes ergonomic considerations that minimize the
physical burden of patient care delivery
Promotes interdisciplinary collaboration
NOW
1. Improved staff
circulation within
core
2. Decentralized
staff stations at
patient rooms
3. Decentralized
meds and
equipment
4. Created team
rooms
1 1
22
3
3
3
3 4
44
4
Design Solutions - Staff
NNOW
Decentralized Nurse/Staff Stations
• Decentralized nurse/staff stations
with patient view window
• Improved view of patients for
assessment purposes
• Encourages staff time with
patients
• Decreases staff travel time
• Distributed supplies/linen
• Creates quieter environment
Storage rooms and alcoves
• Maintain hallways free of
equipment
• Support service areas (Lab,
Nutrition)
TEAM
MEDS
SUPPL
Y
Unit Staff Support Areas
NOW
Inpatient Floors 15–17
Typical patient room Increased room size (ranges from 251 s.f.–298 s.f.)
Outboard toilet improves visibility of patient
ADA-sized toilet enhances accessibility
Improved family space
Easier access to patient
Caregiver work area within patient room
PPE alcove outside room
NOW
DATA
Data Collection
J F M A M J J A S O
BEFORE DATA AFTER DATA
UNIT A
UNIT B
UNIT C
UNIT A
UNIT A NEW
UNIT B NEW
UNIT C NEW
2011
Data Collection Protocol
14 staff data points for day shift/14 data points for
night shift (per unit)
RNs carried PDAs and completed corresponding
pedometer logs
PDA vibrates 30 times/12 hours, tasks and location
entered
Filled out surveys
Data Types
Nursing time:
Rapid Modeling PDA
Walking distance:
Pedometer
Acute stress:
Current Mood State Questionnaire
Presenteeism:
Koopman Stanford Presenteeism Scale
(Modified)
Staff interaction and collaboration
KU Scale
TCAB PDA
PDA TCAB Data Classification
Task Type
Value adding
Non value adding
Necessary
Task Category
Direct care
Indirect care
Administrative
Personal
Waste
Documentation
Other
Task Location
Nurse station
Patient room
On the unit
Patient medication
Supply storage
Conference room
Off unit
Documentation server
Other
FINDINGS
Identifying Patterns of Change
Care processes, physical environment, culture and policies interact
PATIENT
PATIENT OUTCOMES
PHYSICAL ENVIRONMENT
CAREGIVER CARE PROCESSES
GROUP PHENOMENA: CULTURE RELATIONSHIPS
POLICIES
Identifying Patterns of Change
Multiple unit
comparison benefit
Identifying Patterns of Change
Performances change after intervention
The key question is consistency
PDA Task Category: Documentation
15
17
19
21
23
25
27
29
31
33
Unit A Unit B Unit C
Before
After
PDA Task Location: Nurse Station
25
27
29
31
33
35
37
39
41
43
45
Unit A Unit B Unit C
Before
After
PDA Task Location: On The Unit
0
2
4
6
8
10
12
14
16
Unit A Unit B Unit C
Before
After
PDA Task Location: Medication
0
2
4
6
8
10
12
14
Unit A Unit B Unit C
Before
After
PDA Task Location: Supply Storage
0
0.5
1
1.5
2
2.5
Unit A Unit B Unit C
Before
After
Pedometer Walking Distance
1.5
2
2.5
3
3.5
4
Unit A Unit B Unit C
Before
After
Collaboration/ Teamwork
Question Direction Significance?
UNIT PRIMARY WORKSPACE
The amount of space in your primary
workspace fits your needs
UP 1 OF 3
You have sufficient work surfaces in your
primary workspace for your equipment and
work
UP 1 OF 3
You have enough storage space in your
primary workspace
UP 2 OF 3
You can change your workspace as needed
to fit your needs
UP 1 OF 3
PRIVACY IN PRIMARY WORKSPACE
You have enough privacy in your primary
workspace to do your job (e.g.,documentation,
charting, and/or dictation) well.
UP 0 OF 3
Collaboration/ Teamwork
Question Direction Significance?
PRIVACY IN OTHER SPACES
You feel that you are not interrupted by
others as you work in patient rooms
DOWN 0 OF 3
You feel that you are not interrupted by
others as you work in medication room/s
DOWN 0 OF 3
ENVIRONMENTAL FEATURES
Your primary workspace gets enough natural
light
DOWN 0 OF 3
Your primary workspace has sufficient
illumination for your needs
DOWN 0 OF 3
You are able to control the temperature in
your primary workspace when needed
DOWN 0 OF 3
You are able to control air
velocity/movement when needed
DOWN 1 OF 3
Collaboration/ Teamwork
Question Direction Significance?
UNIT WORK SUPPORT
When you need a computer, there is one
available
UP ALL
You can easily monitor your patients from
unit workspaces
DOWN 0 OF 3
The people you need to work with are
available in the unit when you need them
DOWN 2 OF 3
Overall, you are pleased with the design of
your unit in relation to your work
DOWN 0 OF 3
Collaboration/ Teamwork
Question Direction Significant?
COLLABORATION + TEAMWORK
Overall, the layout of your unit supports
teamwork or collaboration
DOWN ALL
Your unit has adequate space for formal
team meetings
UP ALL
Your unit has adequate space for informal
team meetings or interactions
UP 1 OF 3
Meeting spaces are generally available in
your unit
UP 1 OF 3
Patient rooms are large enough for
teamwork and collaboration
UP ALL
Corridors are wide enough for informal
interactions
UP 1 OF 3
Collaboration/ Teamwork
Question Direction Significance?
WALKING
You spend more time walking in your unit in
relation to other activities
UP 2 OF 3
Walking takes away from the time you would
otherwise have for patient care
UP ALL
Walking takes away from the time you would
otherwise have for collaborative work
UP 2 OF 3
Focus Group Interviews
The Nurses Speak…
Increase in computerized documentation
Medication room is now farther from many rooms. Lots
of walking
Location of pneumatic tube station
Finding “other staff” difficult
Different processes for medication record use on each
unit
Lessons Learned
Operational planning vs reality
Paper intensive processes
Added Telemetry reduced ICU census
Geographic patient assignments new reality
Chemo and blood products require two-nurse checks
Feelings of isolation
Missed ‘teachable moments’ for new staff
Infection control discussions
Medications “at the bedside” on the wish list
Cannot get all supplies to the bedside
SUMMARY
Operational design must match physical design
intervention to achieve desired outcome
Culture change is the most important challenge
Unit size and shape appears to be key determining
factors affecting collaboration and teamwork
Healthcare
Pamela Redden, MD Anderson
Cancer Center
Debajyoti Pati, Texas Tech
University