PDC_2012_ED Study

1. First Do No Harm…
How Design Impacts Safe and
Efficient Care in the Emergency
Department
ASHE-PDC 2012, Phoenix, AZ

2. Presenters
Thomas E. Harvey
FAIA, MPH, FACHA, LEED® AP
Partner/Senior Vice President, HKS
President, CADRE
Debajyoti Pati
PhD, FIIA, LEED® AP
Associate Professor, Texas Tech University
Executive Director of CADRE
David Vincent
AIA, ACHA, LEED® AP
Principal/Senior Vice President, HKS

3. Acknowledgments
Institutional Support and Funding
 AIA Academy of Architecture for Health Foundation
 Herman Miller, Inc.
 HKS, Inc.
 Texas Tech University
 Participating Hospitals administration and staff
Study Team
 CADRE – Debajyoti Pati (PI) and Tom Harvey
 HKS – David Vincent, Jennie Evans
 Herman Miller – Doug Bazuin
 Synurgy Healthcare Solutions - Mary Ann Derr

4. Agenda
 Study questions
 Research method
 Safety and efficiency correlates
 Next steps
 Q&A

5. Questions
In what way does the ED physical
design facilitate or impede ED
processes?
What are the domains of physical
design decisions that potentially
influence the efficiency and safety
of ED operations?

6. Method: Study Sites
Palmetto Health in Columbia, South Carolina
Palmetto Health Baptist
Palmetto Health Richland
Texas Health Resources - Fort Worth, Texas
Harris-Methodist Southwest
Intermountain Healthcare - St. George, Utah
Dixie Regional Medical Center PH Baptist
PH RichlandDixie Regional Medical CenterHarris-Methodist Southwest

7. Method: Data Types
 Multi-disciplinary gaming
 Semi structured interview
 Touring interviews of frontline staff

8. Method: IRB / Quality Improvement
 Approved as non “human subjects” study
o Palmetto Health Baptist
o Palmetto Health Richland
o Intermountain
 Approved as “human
subjects” study
o THR Harris-Methodist
Southwest

9. Safety
Safety
Patient
Staff
Family/Visitor
Security affects Safety
in the care processes
Security

10. Efficiency
Nursing
Support
Physician
Efficiency
THROUGHPUT

11. Interactions
SAFETY EFFICIENCY
Security
Safety and Efficiency are both affected
by Security – real or perceived….

12. Findings…

13.  Entry / Public Waiting
 Patient Intake
 Patient Flow
 Configuration
 Room Standardization
 Space Adequacy
 Sub-waiting
Domains of Consideration
 Care-giver Work Area
 Physician Work Area
 Equipment Accessibility
 Behavioral Health Support
 Staff Respite
 Corridor Width
 D & T Adjacencies

14.  Entry / Public Waiting
 Patient Intake
 Patient Flow
 Configuration
 Room Standardization
 Space Adequacy
 Sub-waiting
Primary Domains
 Care-giver Work Area
 Physician Work Area
 Equipment Accessibility
 Behavioral Health Support
 Staff Respite
 Corridor Width
 D & T Adjacencies
Top safety and efficiency priorities!

15. Red = Safety Concerns
Potential safety breaches create
both security concerns and
inherently disrupt efficiency of the
entire care process.

16. Blue = Efficiency Concerns
Patient intake must be rapid and
accurate to initiate and ensure
efficiency and maximum
throughput.

17.  Entry / Public Waiting
 Patient Intake
 Patient Flow
 Configuration
 Room Standardization
 Space Adequacy
 Sub-waiting
Secondary Domains
 Care-giver Work Area
 Physician Work Area
 Equipment Accessibility
 Behavioral Health Support
 Staff Respite
 Corridor Width
 D & T Adjacencies
Second highest safety and efficiency priorities!

18. Blue = Efficiency Concerns
Adequacy of work space for staff
and physician work, within good
line of sight of all exam/treatment
rooms, was the second strongest
point of emphasis.

19. Interactions
SAFETY EFFICIENCY
Security
Every finding within this study affects both
Safety and Efficiency to varying degrees!

20.  Visibility
 Queuing sensitivity
 Security provisions
ENTRY/PUBLIC WAITING

21. ENTRY/PUBLIC WAITING…Visibility
 Full visibility of all waiting areas
 Immediate recognition by staff of patient’s walk-in
urgent condition
 Change in patient
condition while
waiting is detected
and acted upon
 Continuous
monitoring of
traffic and volume
can improve efficient
patient flow and throughput

22.  Provision of waiting areas in zones may promote
efficiency. With a common waiting area, nurses may
have to explain to patients why they are not seen in
the order of arrival.
ENTRY/PUBLIC WAITING…Queuing Sensitivity

23.  Visible security deters potential threat to hospital staff
and patients.
 Security concerns
impact safety and
efficiency -
a psychological
impact.
 Bullet-proof glass
for registration desk.
 Metal detectors at
the walk-in entrance.
ENTRY/PUBLIC WAITING…Security Provisions
Security Office

24.  Adequate counter provisions for IT equipment
 Sufficient area for clinical equipment
 Connectivity (pneumatic tube system)
 Specimen collection
resources
PATIENT INTAKE

25.  Visibility
 Teamwork
 Staffing
 Ancillary Tracking
CONFIGURATION
Linear – Single Door Linear – Double Door
Pods

26. CONFIGURATION…Visibility
 Safety by visibility between
work zones and patient rooms
 Efficiency and security by
sight lines of clinicians to
each other across acuity zones
 Efficiency by sharing across the
acuity zones
 Caution! - Isolated
exam/treatment
rooms cut off from work
core line of sight pose a
safety problem

27.  Caution! - Obstructed visibility can impede teamwork
of clinical staff when back-up assistance is needed
 Caution! - Physicians noted smaller pods of patient
rooms can lead
to perceived and
real isolation
when they are so
small that only
one physician is
warranted in the
area
CONFIGURATION…Teamwork

28.  Staffing adjustments associated with volume
fluctuations over 24 hours can pose efficiency and
real cost issues in the use of human resources.
 Caution! - Pods become inefficient when only a
few rooms are occupied.
 Caution! - Morale and
teamwork are perceived
to be diminished when
staff must split
between pods.
CONFIGURATION…Staffing

29. CONFIGURATION…Ancillary Tracking
Sat
Lab
Rad
Room
Sat
Pharmacy
Imaging
CT
Scan
 Multiple geographic
pods can cause
difficulty locating
patients by support
department staff from
Imaging, Laboratory,
Pharmacy and
Respiratory
Therapy.

30. LEAN operations improvement aside….provide sub-waiting
 At intake for exam room queuing
 In core for results waiting to free up exam rooms
 In core to allow more
flexible room staging
 In core (or holding area) to
await admission or
discharge
 Recommendation!
Provide medical utility
access in these areas
SUB-WAITING

31.  Locate to optimize nurse-patient visibility for safety
 Attenuate intelligible speech from reaching patient
rooms – efficiency as well as privacy.
 Design work stations to minimize potential
distractions from
family members
CARE-GIVER WORK AREA

32.  Optimize visibility of patient
rooms from physician workspace,
 Mitigate potential uninitiated
interaction with family members
or patients
PHYSICIAN WORK AREA

33. Patient
Intake
Configuration
Care-giver
Work Area
Physician
Work Area
Sub-waiting
Traffic
Flow
Corridor
Width
Space
Adequacy
Equipment
Accessibility
D & T
Adjacencies
Staff
Respite
Room
Standardization
Behavioral
Health Support
Summary
Safety and Efficiency…14 domains of consideration
are essential to excellence in ED design.
Entry/
Public Waiting

34. Healthcare
Thank You…