The University of Kansas Health System Post-Occupancy Evaluation (POE) Report

INSTITUTE FOR HEALTH + WELLNESS DESIGN

THE UNIVERSITY OF KANSAS HEALTH SYSTEM POST-OCCUPANCY EVALUATION (POE) REPORT

Photo Credit: JE Dunn https://www.jedunn.com/projects/university-kansas-hospital-cambridge-north-tower

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INSTITUTE FOR HEALTH + WELLNESS DESIGN

THE UNIVERSITY OF KANSAS HEALTH SYSTEM POE REPORT

TABLE OF CONTENT

Executive Summary

PART I: INPATIENT POE Background Research Goals/Methods Research Methods and Outcomes Results

Ambient environment

Noise Lighting Visibility

Behavior mapping

Interaction Space utilization Nurse activities

Walking Distance

Patient Satisfaction

Patient Outcomes

Hand Hygiene

Patient Room Evaluation

Staff Suggested Design Improvement

Nurse Managers’ And Nurses’ Interviews

PART II: IR AND SURGICAL DEPARTMENT POE 3

RESEARCH TEAM

GRAPHIC DESIGN TEAM Thanks to our grahhic designers, Muntoreanu, Roberto and Christopher Koss for developing the final documentation.

Hui Cai, Ph.D.

Kent Spreckelmeyer,

Frank Zilm

Intisar Tyne

Associate Professor

D.Arch, FAIA

D.Arch, FAIA

Ph.D Candidate

Professor

Chester Dean Director

ACKNOWLEDGEMENT

RESEARCH TEAM

Thanks for the support of the University of Kansas Hospital, including Dr. Jennifer Thanks for the help of our students who enrolled in the “Evidence-based Design Research in Healthcare

Williams, Todd Koch, Adam Meier, Stacy White, Miki Mahnke, Katie Mayer, Sarah

Facilities” in conducting some of the data collection, including Intisar Ameen Tyne, Abby Eleeson, Hannah

Villanueva, Libby Nasche, Jason Thomas, and all the nurses who contributed to the

Warren, Yuang Sun, Yuhua Dai, Ercheng Wang, Melissa Watson Jaxon Freeman, Rui Ge, Chris Carrano, and

POE study in these units.

Abigail Kebede. We woulsd also like to thank Ph.D. student Seyedeh Farzaneh Mahlab and her advisor Dr. Hongyi Cai’s support on the lighting measurement, and Brooke Schler, James Davis, and their advisor Professor Jason Pittman’s support on acoustic measurement.

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EXE CU

SUMMARY

EXECUTIVE SUMMARY

The newly completed Cambridge A (CA) tower has implemented several innovative design features, including decentralized nursing unit, family-centered environment, as well as the Interventional Radiology (IR) and surgical department. In order to test the effectiveness of the new design, a systematic post-occupancy evaluation was conducted in the new CA building in comparison with the existing Bell Tower.

The POE has two parts: the first part as the inpatient unit POE and the second part as the surgical department and IR in the CA Tower.

PART I: INPATIENT UNIT POE

Over the past decades, healthcare design has gone through rapid changes to react to the transformation towards patient and family-centered healthcare delivery models.

For instance, traditional centralized nurse stations have been gradually replaced by decentralized work stations for the hypothesized benefits of more time at the patient bedside, less walking distance, and better patient care. However, debates persist on the impacts of decentralized nursing units on nurses’ communication and coordination, and related patient outcome and their perceptions of care quality. Moreover, there are many variations of decentralized nursing unit typologies, however, few studies have compared the effectiveness of various decentralized nursing unit typologies and identified the key elements and characteristics for an optimal layout that can support both staff efficiency, communication, and better patient experience. This project aims to empirically evaluate the impacts of nursing unit typology through a comparative study in the newly constructed Cambridge A (CA) building and the Bell Hospital at the University of Kansas Hospital. The research is based on a quasi-experimental comparative study. It intends to compare one typology of a decentralized nursing unit (CA5 Intensive Care Unit and CA6 Progressive Care Unit) with another typology of a decentralized nursing unit with similar staffing model and patient acuity level (Bell Unit 63 Intensive Care Unit and Bell Unit 64 Medical Transplant Unit) to evaluate the impacts of the physical environment on nurses’ efficiency, teamwork, hand hygiene compliance, and patient satisfaction. Research methods include visibility analyses, noise and lighting measurements, pedometer readings, behavior mapping and tracking, nurse interviews and questionnaires, and patient satisfaction and outcome analyses.

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EXECUTIVE SUMMARY: RESULTS

NOISE

The noise levels at CA6 and CA5 were significantly lower than the noise level at Bell 64 and Bell 63 respectively. The new design allowed better control of noise that provided patients and family with a quieter environment. For CA5 and CA6, there were significantly higher noise levels in the nurse team station than noise in the corridor. For the Bell 63 and Bell 64 units, there was no significant difference between noise in the corridor and noise in nurse team station.

The results showed that overall the two units in Cambridge A provided an increase in overall environmental quality and noise reduction, improved patient care, increased care coordination and inter-professional communication, reduced non-value added

LIGHTING

activities, and better patient outcomes compared to the two Bell units. The patient

Based on the Lighting for Hospitals and Healthcare Facilities standards recommended by the Illuminating Engineering Society (IES, 2011, P.27.16 ), the nurse station has optimal light levels for conducting work tasks (237 lx > 200 lx recommended by the

rooms and associated family support areas have provided a positive, safe, and

code for vertical target viewed by the general population). When all the lights are on

efficient healing environment based on the CHD Evidenced-based Design checklist.

in CA5 and CA6, the light levels are sufficient for examination (200 lx recommended

The primary concerns raised in the new layout of CA were the decreased visibility and

by the standard for 25-65 years old) in both rooms. Rooms facing away from direct

accessibility as the result of the length of the corridor and the shape of the floor plate.

sunlight need additional artificial lighting to support reading.

This resulted in increased walking distances, reduced nurse-to-nurse communication, and possible sense of isolation in CA units in comparison to the Bell units.

VISIBILITY

The units in the Bell hospital have higher visibility and accessibility compared to the units in the Cambridge hospital. Among the four units, Bell 63 has the highest visibility and accessibility compared to the other three units, while CA5 has the lowest visibility and accessibility among them. Central sections in CA units suffer from low visibility and accessibility.

PATIENT ROOM POE

Based on the Center for Healthcare Design standardized patient room POE toolkit,

PATIENT SATISFACTION

After moving to Cambridge A Tower, the mean score of CA5 overall patient

for the 23 EBD goals, the average score of CA5 is 24% higher than Bell 63 (4.41 vs.

3.33) and the average score of CA6 is 18% higher than Bell 64 (4.56 vs. 3.73).

satisfaction ratings improved from 91.5 to 92.2, which is an increase of 0.8 percent, and the mean score of CA6 also improved from 89.3 to 90.8, which is an increase of 1.7 percent. Since we didn’t have access to monthly data and individual patient-level data, we are not able to conduct statistical analyses to determine the significance of these findings.

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PATIENT OUTCOME

Overall, patient outcomes improved in the two new CA units. For CALBSI and C.Diff, Bell 63 ICU had higher total incidents and average monthly rates after the study period than during the period before. Bell 64, CA5, and CA6 all reduced the CALBSI

NURSE ACTIVITIES

The results from the behavior mappings show that the new CA units have less percentage of non-value added activities compared to the Bell Units, which led to a higher percentage of patient care activities. In addition, the team room in CA6

and C. Diff total incidents and monthly rates. For falls, the two Bell units have similar

allowed a higher percentage of care coordination activities than Bell 64.

rates before- and after-move, but the CA5 and CA6 have dramatically reduced rates

Nurses of the progressive units walk more often than the nurses of the ICU units.

during the after-move period (50% and 58% respectively). For HAPI, Bell 63 had a

Nurses in Bell 64 frequently look and retrieve, which results in more frequent walking

lower monthly rate and overall incidents during the after-move period than before,

when compared to the other units.

however, Bell 64, CA5 and CA6 had much higher HAPI rates after the move.

HAND HYGIENE

When comparing the hand hygiene compliance rates before- and after-move to the Cambridge A tower using the hospital-provided data, CA5 ICU had higher rates

NURSE INTERACTIONS

Nurse-to-nurse interaction and nurse-to-patient interaction is higher in the Bell 64 (44.3% compared to CA6 36.8%). On the other hand, interaction with family members, doctors, and therapists in Cambridge hospital is higher compared to the doctor-

after the move from the Heart Hospital (94% versus 91%), while CA6 had similar

nurse interaction in the Bell hospital. Nurses of CA5 (45.5%) and CA6 (44.2%) had

compliance rates (93% versus 93%). The average hand hygiene compliance rates for

more frequent interactions when compared to the work-related interactions of Bell

Bell 63 ICU (95%) is higher than CA5 ICU (92%).Our observation data demonstrates

63 (39.9%) and 64 (29.3%). By contrast, the rate of social interaction is higher in the

that both Bell units have a fewer number of gel-based hand sanitizer dispensers,

units of Bell hospital compared to the units of Cambridge hospital.

but higher visibility and accessibility to these dispensers when compared to their matching units in CA, which led to higher hand hygiene occurrence rates in the Bell units. This is consistent with the hospital reported data.

SPACE UTILIZATION

The data gathered through the behavioral mapping demonstrates that nurses of

The results showed that RNs in the progressive care units (Bell 64 and CA6) walked

WALKING DISTANCE

significantly more than nurses at ICU units Bell 63 and CA5. On average, the ICU nurses walk about 2.18 miles and progressive care nurses walk 3.10 miles. The RNs in both CA units walk significantly more than their peers at the Bell units. On average,

the ICU units visit patient rooms, nurses stations, and nurses’ alcoves more often

the Bell 64 nurses walk about 2.81 miles and the CA6 nurses walk 3.34 miles, and the

compared to the nurses of the two progressive units. In terms of the ICUs, both

Bell 63 nurses walk about 1.91 miles and the CA5 nurses walk 2.41 miles.

units have similar visits to patient rooms, but the new design of CA allows nurses to utilize the alcoves more often, hence provide closer contact with patients and family. Team rooms in CA5 and CA6 are frequently used, which can lead to better care coordination and inter-disciplinary communication. There was a reduction in the frequency of patient room visits in CA6 compared to Bell Unit 64.

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INTERVIEWS WITH UNIT MANAGERS AND A SAMPLING OF NURSING STAFF SUMMARY Semi-structured interviews with the four unit managers and a random sample of

Nurses on Cambridge 5 were positive about the patient-room sizes and standardized

interviews with between nine and fourteen nurses on each of the four units were

configurations, placement and number of computers throughout the unit, the aesthetic

used to collect anecdotal data about the perceptions of how the units operated

quality of the unit, and the location and design of the team room and support areas.

on a daily basis, the environmental quality of the units, and how the design of units

The most consistent concerns were focused on the unit size for critical-care patients,

could be improved.

All the managers were satisfied with the ways their own unit

the length and isolation of the two corridors, the visibility difficulties caused by the

layouts and designs created a positive care model. The managers in Bell Units 63

corridor bends, and the sense of isolation, both along the length of the unit and

and 64 thought the compact central cores, square or elliptical floor plates, and even

between the Cambridge A Tower and the main hospital campus. The perceptions of

distribution of nurse stations contributed to efficient operations and allowed nurses

nurses on Cambridge 6 paralleled those in Cambridge 5 in most areas, although they

to match daily assignments with a variety of home bases. Their primary concerns

were not as concerned about the overall unit size. They were most positive in their

in Units 63 and 64 were the small size and non-standardized configurations of the

assessment of the size and configuration of patient rooms, the extent, and placement

patient rooms, the noise created in the compact core design, and general lack of

of computers throughout the unit, the family accommodations, and the overall

storage and family-support spaces. Nurses on Bell Unit 63 were positive about the

aesthetic quality of the spaces. They felt the design of the unit had improved the

size of the unit, the compact central arrangement of nurse stations and support

lighting quality, reduced noise, and enhanced exterior views from the environments

core, and ability to communicate effectively with their colleagues. The compact

in the Bell and Heart units. Their primary concerns were focused on the length of the

unit layout contributed to good surveillance of patient rooms and other nurses but

units, visibility difficulties caused by the bends in the floor plates, and the isolation of

also caused excessive noise and crowding, especially during rounds.

the staff along the corridor lengths and across the opposing corridors.

The small

patient room sizes, non-standard layout, and lack of storage were concerns of the nursing staff. The extent and configuration of computers throughout the unit were evaluated positively. Similar opinions were expressed by nurses in Unit 64 as those in Unit 63, except the former were not concerned about small patient-room size or non-standard room configurations.

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PART II: INTERVENTIONAL PLATFORM AND SURGERY POE

PREP/ HOLDING

The surgery prep/holding area includes 29 “universal” bays capable of supporting patient preparation and recovery. This model is designed to allow rooms to swing between prep and recovery as demand requires, moving away from the traditional concept of a separate post-anesthesia recovery room. Staffing is currently organized to focus recovery functions at the south end of the unit, with an adjacent bank of rooms that can swing between recovery and prep.

Staff feedback and limited

observation indicate that this model is working well for the service. A sample of bed utilization through the day indicates that there is currently spare capacity. Long surgery case times are the primary factor in the low peak activity census. Two of the

SURGERY

existing rooms are being used by cardiology and two rooms at the south end have The evaluation of surgical and interventional services included the assessment of

low utilization.

overall space allocations, utilization of areas, and functional performance. Due to the nature of procedures performed in these areas, the concern for sterile processes, and

The bay sizes are functional for both prep and recovery functions.

stress on patients, staff, and families, the scope of this analysis did not include the

readings and observations indicate low noise levels with minimal ability to overhear

level of observation incorporated into the inpatient analysis.

conversations in adjacent rooms. Including sliding walls between holding rooms

Acoustical

increases the sound transfer between rooms. The sliding wall feature appears to be Current surgery procedures performed on the third floor of Cambridge A include

used more in the recovery area than during the prep phase.

cancer, neurosurgery, ENT and other cases. The ratio of overall departmental gross

The original layout of the rooms anticipated a staff work zone of the left side of the

square footage for the eleven operating rooms is 4,300 DGSF. This is significantly

patient bed (facing the bed), with a family zone on the right side. The installation of

higher than current industry benchmarks of 3,000 – 3,500 per room. Inclusion of

a wall bracketed computer terminal on left side of the headwall has limited the ability

specialized spaces (MRI, anatomical pathology), larger staff support spaces than

to place mobile supply carts on that side of the rooms, requiring staff to cross the

typical, building circulation components, and a high ratio of holding/recovery rooms

patient zone to access supplies relocated to the right side of the room.

to operating rooms contribute to the high ratio.

High utilization of the consultation rooms near the family waiting area were reported.

We were not able to assess the effectiveness of the split in waiting areas between the first and second third floors.

STAFF INTERVIEWS

Overall, staff interviews indicated satisfaction with the facilities in Cambridge A. Some conflicts with the location of scrub sinks and staff flow were identified.

The location of patient toilets in the prep area was cited as a concern, with more central locations suggested as preferable.

Storage space for patient carts are

remote from the prep area, resulting in holding carts in the corridor of the prep area. Underutilization of space near the case cart/supply elevators at the north end of the floor was also pointed out by staff. The inclusion of a satellite pharmacy and the anatomical pathology area are significant support functions for the procedures performed in this area.

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OPERATING ROOMS

The operating rooms are divided into two clusters, with the core thee neurosurgery rooms and the MRI at the south end of the space and the eight remaining operating rooms arranged in a sterile core model on in the main floor area. The room sizes

PREP/ HOLDING

The twelve holding rooms are clustered in a “ballroom” configuration around a central work station. The average size of a room 122 net square feet. Sample acoustical reading indicate acceptable noise levels, with spikes related to family

vary from 660 NSF to 770 NSF, which is consistent with current norms for rooms

conversations and door openings. One of the twelve holding rooms is designed for

supporting procedures requiring significant equipment and staff. The “universal

patient infectious isolation, which is a low percentage of cases.

room” concept is working effectively, except for selected specialized procedures,

A sample of the holding/prep bed utilization indicated capacity to accommodate

such as some ENT cases. The use of the DaVinci robotic equipment and the need

growth. Inpatients are frequently moved directly into the procedure rooms, bypassing

to locate anesthesia away from the head of the patient have resulted in the diagonal

the holding area and high-risk patients are moved directly back to intensive care or

rotation of the patient in the rooms. This results in the location of the surgical field

other units.

near the higher circulation areas of the room (corridor access to the O.R., access to the core, scrub sink access, and the circulating nurse work areas). The location of the control terminal for the Da Vinci unit may also conflict with the return air circulation in the room. The diagonal location of the patient does not take advantage of the laminar airflow concept built into the universal room layout.

PROCEDURE ROOMS

The procedure rooms are in a “mirrored” layout with a single control area between the rooms. The room layouts are functional, with good visual observation into the rooms from the control area. Some procedures require multiple clinical teams and equipment limiting circulation and work areas.

We were unable to schedule interviews with staff to assess their feedback regarding this space.

INTERVENTIONAL SERVICES The core interventional imaging services located on the second level of Cambridge A include two biplane fluoroscopy imaging procedure rooms, diagnostic CT and fluoroscopy rooms, holding/recovery, and a waiting area. In addition to the procedure/diagnostic rooms, the holding area also supports prep/recovery for an adjacent MRI room.

One shell area located next to the biplane rooms is sized for

future expansion of these procedures.

The area allocated for this service is approximately 15,000 departmental gross square feet. A main public circulation corridor between a staff parking garage and the hospital bisects the waiting area, resulting in a linear configuration.

The workload for the interventional imaging procedures is current relatively low for the capacity of the system.

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PART I

KU HEALTH SYSTEM INPATIENT UNIT POE REPORT 19

BA CK GRO

Photo Credit: Cannon Design

A nursing unit is a basic unit in a hospital or other health care delivery setting that provides the necessary functions for health care professionals to deliver care to their patients. The layout of the nursing unit is strongly driven by the location of nurse station(s) and its relationship to patient rooms and other support areas. Traditional nursing unit design is usually based on one central nurse station located in the middle of the unit to overlook most of the patient rooms. Recently, the contexts in which the healthcare organizations operate have changed dramatically, such as the shift to patient and family-centered care, more integrated care processes and collaborative care models, and rapid updating of technology and equipment. As a result, traditional centralized nurse stations have been gradually replaced by decentralized work stations, for the potential benefits of better patient visibility, increasing direct patient care time, and reducing walking distance. However, debates persist on the impact of decentralized nurse stations on nurses’ communication and coordination. Moreover, there are many variations of decentralized nursing unit typologies. Few empirical studies have compared the effectiveness of various decentralized nursing unit typologies and identified the key elements and characteristics for an optimal layout that can support both staff efficiency, communication, hand hygiene, and better patient experience.

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Figure 2. CA6 plan colored by in the middle of the unit.

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Figure 1. Campus map with four study units highlighted

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departments, and 5th-11th floors as inpatient units. It was occupied in Nov.1. 2017. The

Bell 64

CA 6 It is an 11-story building with the first two floors as interventional radiology and surgical

are not standardized.

Bell 63 The Cambridge A (CA) building is a recent addition to the KU Hospital campus (Figure 1).

CAMBRIDGE A

implemented in the design, including dedicated family

SETTINGS

features friendly family/visitor several are There

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THE BELL HOSPITAL

The Bell Hospital was constructed in the 1970s and served as the primary inpatient environment for the KU healthcare system until the construction of the Heart Hospital in the early 2000s and the Cambridge A Tower in 2017. The 6th floor Transplant Intensive

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Care Unit (Bell Unit 63) has 14 beds and the 6th floor Transplant Unit (Bell Unit 64) has

35,423 GSF, which makes 1,265 GSF/bed. The average

24 beds. Both units underwent substantial renovations in 2008 to add nursing alcoves

distance from nurse station to patient rooms is 95 feet,

between each pair of patient rooms.

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BELL UNIT 63

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Figure 4. Bell 63 plan colored by patient zone (blue),

distance from nurse station to patient rooms is 45 feet,

staff zone (gray), and nurse station (red)

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Figure 3. CA5 plan colored by patient zone (blue), staff

the unit for family/visitor accommodation except in the

zone (gray), and nurse station (red)

patient rooms themselves.

25

Figure 5. Bell 64 plan colored by patient zone (blue), staff zone (gray), and nurse station (red)

BELL UNIT 64 Bell Unit 64 is configured on a rectangular floor plate, with a race-track corridor system (Figure 5). The primary unit and visitor entry is on the west, and there is one inter-unit entry at the south quadrant on the east. In addition to the nursing alcoves between each pair of patient rooms there are four nursing substations, one each at the east and west ends of the rectangular floor plate and two paired at the center of the unit. These substations anchor a central support core of staff lockers and break rooms, medication, utility and conference rooms, and four private offices. There

COMMUNICATION TECHNOLOGY

is a small family waiting room, a work room and a private office at the west entry.

Each patient room has a private patient toilet. The patient rooms are configured in a relatively standardized layout in mirrored plan arrangements. The room size varies from 226 NSF (with a 42 NSF private toilet) to 325 NSF (with a 57 NSF private toilet).

The average patient room size (excluding the private patient toilet) is 244 NSF. The overall unit size is 15,600 GSF, which computes to 650 GSF/bed. The average distance from nurse station to patient rooms is 60 feet, the max is 140 feet, and the min is 18 feet. The average distance from nurse station to clean supply is 37 feet, the average distance from nurse station to medication room is 42 feet, the average distance from nurse station to soiled supply is 41 feet. There are no areas within the unit for family/visitor accommodation except in one small waiting room and in the patient rooms themselves.

In all of these units, a number of communication technologies are adopted, including Voalte phones, Sonitor nurse locators, and nurse pagers. Several Workstations on Wheels (WOW) were provided in each unit to support mobility of rounding and charting.

In both the ICU unitsâ&#x20AC;&#x2122; nurses have the same amount of workload. In both the ICU units nurse to patient ratio is 1:2.

Both acute care units (CA6 and Bel 64) also have similar staffing model and nurse to patient ratio as 1:4 to 1:5. Bell 63 and Bell 64 are compatible control groups for CA5 and CA6.

27

RE SE AR

RESEARCH DESIGN AND GOALS This project aims to empirically evaluate the impacts of decentralized nurse stations through a multi-center, before-and-after,

quasi-experimental

comparative

study in the newly constructed Cambridge A building and the Bell Hospital. It intends to compare one typology of decentralized nursing unit (CA5 ICU and CA6 Progressive care unit) with another typology of decentralized nursing unit with similar staffing models and patient acuity levels (Bell Unit 63 ICU and Bell Unit 64 Medical Transplant Unit) to evaluate the impacts of the physical environment on nursesâ&#x20AC;&#x2122; work efficiency, teamwork, hand hygiene, and patientsâ&#x20AC;&#x2122; outcomes and satisfaction.

RESEARCH METHODS This study combines both qualitative and quantitative methods to examine how various users function in these units with a focus on nurses. Research methods include visibility analyses, noise and lighting measurements, pedometers, behavior mapping and tracking, nurse interviews and questionnaires, and patient satisfaction and outcome analyses.

29

1. VISIBILITY ANALYSIS OF BOTH PLANS USING SPACE SYNTAX

We used the program Depthmap to conduct space syntax analysis and describe the patterns of visibility.

1.

ROUTES AND SAMPLING POINTS FOR NOISE MEASUREMENT

2.

Moreover, we evaluated the visibility (integration) of the hand sanitizer stations to see if the visual cues of hand sanitizer station impact hand hygiene compliance.

2. NOISE AND LIGHTING

The ambient environment, including lighting and noise levels, was measured in each unit. The noise levels were measured at several sampling points within each unit in the morning and afternoon during the 5-day observation period (Figure 6). The researchers walked along a predetermined path and measured noise at each sampling point for one minute. For the background

3.

noise level measurement, the research team used the Decibel X app and further calibrated with a sound level meter (model number: Larson Davis 831). Noise levels at 18 sample points are equally spaced out in the CA5 unit and CA6 unit. Among them, 4 sampling points (6,8,14, and 15) are inside the decentralized nurse station and the other 14 points are along the corridor. Similarly, noise levels at 15 sample points that are equally spaced out in Bell 64 and 12 sampling points in Bell 63 were

4.

measured. Among them, 4 sampling points are inside the sub- nurse stations (6,10,12 & 14), and the other 11 points are along the corridor in Bell 64; 3 sampling points are inside the sub-nurse stations (3,7&11), and the other 9 points are along the corridor in the Bel 63.

Figure 6. Noise Sampling routes and points in 1. CA6 2. CA5 3. Bell 63 4. Bell 64

31

LIGHTING MEASUREMENT

3. PATIENT SATISFACTION

The lighting measurement of luminance using a Minolta

The patient satisfaction data will be obtained before and after moving to the

T-10 was conducted on the patient’s bed in two selected

decentralized nursing unit design. The focus of the analysis is on patients’ perception

patient rooms, simulating the patient’s typical points

of the physical environment and care quality. After obtaining the satisfaction data,

of view between 10:00 AM and 12:00 PM on October

the descriptive statistics will be used to compare the average values before- and

22 and 26, 2018 (Figure 7). The two selected patient

after- the move for the Cambridge A units, and compare the average values of CA

rooms were located in the CA 6 progressive care unit.

5 ICU with its control group of Bell Unit 63, as well as the average values of CA6

Room 607 had a north-west facing window and Room

Progressive Care unit with its control group of Bell Unit 64 during the same time

630 an east facing window, which provided daylight

period. A t-test will be further conducted to see if the differences are statistically

for each room. Electric lighting includes four LED down

significant upon receiving the individual level patient satisfaction data.

lights (for general lighting) and four more LED linear panels recessed on the ceiling or in the ceiling-wall

a) All lights on

intersection. Figure 8 (a) and (b) present the general

4. ANALYSIS OF PATIENT OUTCOME DATA

light and all ceiling LEDs in the patient’s room. For the convenience of the nurses and patients, there were wall switches and remote controls for controlling the

Patients’ outcome data including fall rates, medical errors, and hand hygiene

LED luminaires in the room. The wall switches have

compliance six-months prior to the move into the Cambridge A and six-months after

preset options like ‘bed light’, ‘operation light’, ‘general

the occupancy of the new units were requested from the hospital. In addition, the

light’, and ‘all lights on/off’. In this study, each patient

patient outcome data was compared between CA5 ICU with its control group of Bell

room was measured under three lighting conditions as follows: Daylight only, Daylight + general lights, Daylight + all lights on.

b) General lights only

Figure 8 (a,b). General lights and all lights on in

patient room Additionally, the luminance level in the south team station was measured around 1:00 PM on October 26, 2018, simulating the point of view of a nurse sitting

Unit 63, as well as the average values of CA6 Progressive Care unit with its control group of Bell Unit 64 during the same time period after the occupancy of the new units.

5. PEDOMETER Pedometers were used to collect data on nurses walking. Volunteering nurses were equipped with the pedometers at the start of their respective shifts. These were turned in at the end of the shifts after recording data on corresponding logs.

Pedometer data were collected continuously over a period of one week for all nurses during both shifts.

at her desk and looking toward her monitor.

Figure 7. Patient Room Lighting Measurement

Figure 9. Nurse station illuminance measurement 33

7. SEMI-STRUCTURED INTERVIEWS

Behavior mapping was used to capture the aggregated

The interviews have two phases, one with unit managers

nurses, their perception of the nursing unit design. The

and the other with nurses. For the nurse managers’

awareness level is a good indicator of the sense of

interviews, the questions include the introduction of

community and social support, since nurses need to be

the unit, patient profile, staffing model, a-day-in-the-life

continually aware of what peers are doing to provide

of the unit operation, their perceptions of the design,

timely help. They were asked about their perceptions of

and feedback regarding how the space support work

the design and whether they think the design supports

efficiency, communication, teamwork, and patient care

their work flow, patient care, communication with

delivery. Each interview lasted about one hour.

peer nurses and other health professions, teamwork

patterns of people’s distribution and interaction in the setting. The data were collected by researchers over a period of one week on each unit. The observers documented the physical locations of all those present in the unit via a standard route. Each cycle was approximately 15 minutes. The identity of people and their status of work interaction/social

interaction/non-interaction,

sitting/

standing/moving, and their activities using a predefined category

(waiting,

looking/retrieving,

delivering,

unit-related functions, care coordination, medication administration, documentation, assessment/reading vital signs, patient care activities, hand-wash, break/personal were recorded.

In total, 40 sets of behavior mapping

( !! ( ( ! ! ( ( ( ! !

( !

accepted nursing literature. Please see the example table

( ! ! ( ( !

( !

below (Table 1).

( ! (! ! (! ( ( ! ( ! ! ( ( !

Table 1. Coding of Nursing Activities W L

( (! ! (! !! ( ((! ( ( ! ! ( !

DE ( !

U

(! ! (! ! ( (! ( ( ! ( ( (! ! (! ! ! (

narcotics, transporting patients, using fax or copy machine, review

( ! ( ! ( ! ! ( ( ! ( ! ( ! (! ! ( ! ( ( (! ! ( ! ( ! ( !

NURSING ACTIVITY CODE

UNIT-RELATED FUNCTIONS (preparing equipment, counting

( ! ( ! (! ! ( ! ( ( ! ( ! ( ( ! !! ( ( !

( ! ( !

the unit, their awareness of the location of their peer

8. QUESTIONNAIRES ON NURSES’ PERCEPTION OF DECENTRALIZED NURSE STATION To obtain triangulation date to supplement the observational data, we have developed a survey to collect nurses’ perception of decentralized nurse station design, their communication and collaboration, perceived teamwork.

The questionnaires has been shared with the hospital and will be distributed electronically. At least 50 responses will

( ! ! ( ( ! ! ( (! ! ( ! ! ( (( ! ! (

( ! ( !! (

( ! !! ( (

AD

( ! (! (! !! ( (! ( (! (( ! (! ! (!

ADMINISTRATION/TEACHING

! ! ( ( ( ! ( !

F

! ( ( ! ( (! !

PATIENT/FAMILY CARE

( ! ( ! ( ! (( ! ! ! (

B

( ! !! ( ( (!

BREAK/PERSONAL TIME

( ! (! ! ( ((! ! (! ! ( ! ( ! !( (

H

( ! (! (! (! (! ( (! ! ( ! !! ( (

P

HAND-WASH

( (! ! ( (! ( ! ! (! ! ( ( ! ( ! ( ! ( ! ( ! ! (! ( (! (! ! ( ! ( ! ( (! ( !

PATIENT CARE ACTIVITIES

( ! ( ! ( ! ( ! ! (

A

( !

ASSESSMENT/READING VITALS

M DO

( ! ( ! ( ! ( ( ! (! ! ( ! ( ! ( ! ( ! ( ! (! ! ( ( ! ( ! (! ! (! (! ! (! ( ( ( ! ( (! ! ( ! ( ! ( ! ( ! ( (! (! (! ! (! ! (! ! ( (! (! ( ( (! (( ! (! ! (! ( ! !! ( (! (! ! ( ! ( ! ! ( ( ( ( ! ( (! ! (! ( (! ! (! ! (! ( !

DOCUMENTATION

( ! ( ! ! (

MEDICATION ADMINISTRATION

C

!! ( (

( ! ! (

or update status board.)

CARE COORDINATION

understanding their awareness of what is going on in

(! ! ( ( ! ( ! ! (

The predefined nursing activities were based on widely

DELIVERING

conducted in each unit.

(! ( !! ( ( !

ArcGIS desktop (Figure 10).

LOOKING/RETRIEVING

delivery, and charting. At least 10 nurse interviews were

structured interview. The questions were related to

( ! ( (! ! ! (

morning and afternoon shifts. All data were input into

WAITING

Nurses in each unit were approached for a short semi-

( !

were recorded in each site, covering equal amounts of

NURSING ACTIVITY

and social support, visual surveillance, patient care

( (! (! ! ( ! ( ( ! ! ! ( ( ! ( !

time, patient family care, and administration/teaching)

( ! ( ! ( ! ( ! ( ! ( ! ( ! (( ! (! ! (! ! ( ( ! ( ! ( ! (! ( ! ( ! ( ! ! ( ! ( ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( (! ! ( ! (! ! ( ( ! ( ! ( ! ( ! ( (! ( ! ( ! (! ! ( (! ! (! ( ! (! ! (! ( ! ( ! (! (! ( ! ! (! ((! ( (! ! ( ! (! ( ! (! !! ( ! ( ! ((! ( (! ! (! (! (! (! ! ( (( (! (! (! (! ( ! (! ! ( ( (! ( (! (! ( ! ( (( ! (! ( ! (! ( ! ( ! ! ! ( ( (! ! ( ! (! ! (! ( ( ! ! ( ! (! ! ( ! (! (! ! (! ! ( ! (! ! ( ! (! ( ! (! (! ( ( (! ! (! ! (! (! ( ! ( (! ! (! ( (! ( ! ( ! ( ( ! (! ! ( ! ( ( ! ! ( (! ! ( ! ( ( ! ( ! ( ( ! ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ! ( ! ( ! ( ! (! ( ! (! ( ! ( (! ( ! ( ! ( ! ( ! (! ! (! ! ( ! ! (! ( (! ( (! ! ( ! ( ( ! (! ! ( ! ( ( ( ! ( ( ( (! ! (! ( ! (! ! ( ( ( ! (! ( ! (! ! ( ! (! ! ( ! (! (! ( ( (! ! (! ! ( ( ! ! (! ( ! ( ! ! (! ( ! ( ! ! ( ! ! (( ! ( (! ! ( ! ( ! (! ! (! ! ( ( ! ( ! ( ! ( (! ! ( ( ! ! (! (! ! (! ! ( ! (! ( ! ( ! ( ! ( ! ( ( ! (! ! (! ! ( (! ( ! ( (! ! (! (! ( (! ! ( (( ! ( (! ! ( ! (! ! ( ( ! ! (( ( ! ( ( ! ( ! (! ( ! (! ! ( ( (! ! (! ! ( ( ! ( ! ! ( ! ( ! ( ! ! ( ( ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ( ! ( ! ( ! ( ! ( ( ! ( ! ( ! ( ! ! ( (! ! (! ! ( ! (! ! ( ( (! ! ( ! ( ! (! ! ( (! ! ( ! ( ! (! ( ! ( ! ! ( ( ( ! ( ! (! ! ( ( ! ( ! ( ! ( ! (! ! ( ! ( ! ( ! ( ! ( ! ( ! (! ! ( ! (! ! (! (! ( ! ( ( ! ( ! ( (( ( ! (! ! ( ! (! ! ( ! ( ! (! ( ( ( ! (! (! ! (! ! ( ( (! ! ( ( ! (! ! ( ! (( ! ! (! ( ! (( ! (! ( ! ( ! ( ( ! (! ! (! ( ! ! ( ( ! ( ! (! (! ( ! ! ( ! ( ! ( ( ! ! ( ! (! ! ( ! ( ( ! ( (! ! ( ( ! ( ! ( ! (! ( ! ! (! (! ! (! ! (! ( ! ( ( (! ! (! ( (! ! ( (! (! (! ( (! ! (! ! (( ! ( ! ( ! ! ( ( ! ( ! ( ! (! ! ( ! ( (! ! ( ( ! (! ! ( (! (! (! ! (! ! ( (! ! ( ( ! (! (! (! (! ! (! (! (! (! ! (! ( ( (! (! ( ! (! ( ! ( ( (! ! (! ( ( ! ! ( ! ! ( ( ! (! ! (! ( ! ( ! ! ( (! ( ! (! (! ( (! ! (! (! ! ! ( (! ( (! ( ! ( ! ( ! (! (! ( ! ( (! ! (! (! ! ( ! (! ! ( ( ! ! (! ( ! ( ( (! ! ( ! ! (! ((! ( (! ( ! ( ! ( (! (! ! (! ( ! ( ( ! (! ! (! ! (! (( ! ( (! ! (! ( ( (! ( (! ( ! ( ! (! ! ( (! ! ( ! ( ( ! ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! (! ! ( ! ( ( ! (! ! ( (! ( ! ( ( ! ( ! ( ( ! ! (! (! ! (! ! ( ! ( ! ( ! ( ! ( ( ! ( ! ( ( ! (! ! ( ( ! (! ! ( ( (! ( (! ! (! ! ( ! ! (! ( ! ! (! ( ! ! (! ( ( ( ! (! ! (! ! (! ! (! (! ! (! (! ( ! (! ! ( ! ( (! ! ( ( ( ( ! (! (! (! ( ! ( ( ! ( (( (! (! (! ( (! ( (! ( ! ( ! ( ( ! ( ! (! ! (! ! (! ! ( (! ! ( (! ( ! ! (! ( (! (! (! ! ( ! (! ( ( ! ( ! (! ! (! ! ( (( ! ( (! (! (! ! (! ! (! ! ! ( (! ! ( ! (! ! ( ! ( ! (! ! ( ! ( ( ( (! ! ( (! ! ( (! ! ( ! ( ! ! (! (! ! (! ! ( ! (! ( ! ! (! ! ( ! ( ( (! ( ! (! ! ( ! ! ( (! ! ( ! ( ( ( ! (! ! ( ( ! ( ! (! ! ((! ! ( ! ( ( ( ( ! ( ( ! ( ! (! ( ! ( ( ! ! ( ! (! (! ! (! (! ! (! ! ( ! (! ( ( ( ! ( (! ! (! ! (! ! ( ( ( (! ( ! (! (! (! ! (! ( (! ( (! ! (! ! ( (! ( ( (! ( ! (! ( ! ( ! (( ! (! ( ! (! ! (! ! ! !! ( ( ! ( ! ( ! ( ! ( ! ( ! ( ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( (! ! (! ! !! ( ( (! ! (! (! ( (! ! ( ! ( (! ( ! (! ( ! (! ( ! ( ! ( (! ! (! (! (! ( ( ! (! ( ( (! ((! (! (! ! (! (! ( (! (! ! (! (! ! (! ! ( ! (! ! (! ! (! ( ! ( ! (! (! (! ( (! ( ( ( ( (! ! (! ! (! ! (! ! (! ( (! ! (! ( (! ( ! (! !

6. BEHAVIOR MAPPING

be expected to meet the standard of sample size. We are waiting for the return of survey results to complete the analysis.

Figure 10. Nurses’ Behavior Mapping data in CA 6 35

RE SUL

AMBIENT ENVIRONMENT QUALITY : NOISE In total, 1773 readings were taken in four units for the maximum, average, and peak values of the noise levels over morning and afternoon shifts. Detailed numbers of measurements are listed below (Table 2).

Based on 144 noise readings, CA6 average noise level is 56.1 dbA, the average noise level for the corridor is 54.8 dbA and the average noise level for nurse stations is 60.7 dbA. By contrast, based on 135 readings, Bell 64 average noise level is 58.3 dbA, the average noise level for the corridor is 57.9 dbA and the average noise level for nurse stations is 58.5 dbA. For the ICUs, CA5 average noise level is 55.2 dbA, the average noise level for the corridor is 54.0dbA and the average noise level for nurse stations is 59.2dbA. Bell 63 average noise level Table 2: Number of Noise measurements by unit and by

SHIFT

the average noise level for nurse stations is 60.7dbA. All of the noise levels have exceeded the ASHRAE recommended noise range of 30-

shift UNIT

is 60.3dbA, the average noise level for the corridor is 60.1dbA and

CA6

144

Bell64

135

CA5

180

Bell63

132

Morning

132

Afternoon

132

35 dbA and FGI recommended range of 40-50 dbA (Table 3).

37

UNIT COMPARISON

The independent-samples t-test was conducted to compare the noise level at the

There are significant differences for the noise levels at corridor between CA6 and

two units in Cambridge Tower (CA6 and CA5 ICU) and their matching control units

Bell 64 (M=54.80dbA, SD=5.576 and M=57.92 dbA, SD=9.402) and between CA5 and

in Bell Hospital (Bell64 and Bell63 ICU).

Bell 63 (M=53.99dbA, SD=5.532 and M=60.13 dbA, SD=8.749), t (155.175) =-2.885, p=.004 and t (152.649) =-6.161, p<.001, respectively. Bell units have significant higher

For the progressive care units, the noise levels at CA6 (M=56.1 dbA, SD-=6.125)

noise levels in corridors than CA units (Table 4 & 5), in other words, Bell units has

are significantly lower than the noise level at Bell64 (M=58.34 dbA, SD=8.971),

higher noise from patient/familyâ&#x20AC;&#x2122;s perspective when they are out in the public

t(234.71)=-2.41, p=.017. For the ICUs, the noise levels at CA5 (M=55.2 dbA, SD-=5.818)

corridor. There are no significant difference in nurse stations between CA6 and Bell

are significantly lower than the noise level at Bell63 (M=60.28dbA, SD=8.813),

64 and between CA5 and Bell 63, which might be related to the fact that the nurse

t(212.255)=-5.822, p<.001.

stations in these four units have similar alarm system and work pattern.

Bell units have significant higher noise levels in corridors than CA units, in other words, Bell units has higher noise from patient/familyâ&#x20AC;&#x2122;s perspective when they are out in the public corridor. There are no significant difference in nurse stations

Table 4. Comparison of noise levels at different locations in CA6 and Bell64

Noise Level (dbA)

CA6

NS

between CA6 and Bell64 and between CA5 and Bell 63, which might be related to the fact that the nurse stations in these four units have similar alarm system and work pattern.

Table 3. Noise levels at each unit

LOCATION COMPARISON

dbA

Max

Average

Peak

CA6 Average (dbA)

69.6

56.1

75.3

Bell64 Average (dbA)

72.2

58.3

78.9

CA5 Average (dbA)

68

55.2

73.7

Bell63 Average (dbA)

71.4

60.3

79.4

An independent-samples t-test was conducted to compare noise levels at the corridor and at nurse team stations in the units in both Cambridge and Bell Tower. For CA5

CA6

CA6

Bell 64

CORRIDOR

Bell64 NS

Bell64 CORRIDOR

Total Average

56.1

60.7

54.8

58.3

58.5

57.9

Day Average

57.3

60.7

56.4

57.7

57.7

57.7

Night Average

54.9

60.7

53.2

58.8

60.9

58.1

Table 5. Comparison of noise levels at different locations in CA6 and Bell64

Noise Level (dbA)

CA6

CA5 NS

CA5

Bell 63

CORRIDOR

Total Average

55.2

59.2

54

Day Average

55

59.9

53.6

Night Average

55.3

58.5

54.4

Bell63 NS

Bell63 CORRIDOR

60.3

60.7

60.1

61

62.4

60.6

59.7

59.4

59.81

and CA6, there was a significant higher noise in nurse team station (M=59.20 dbA, SD=4.968 and M=60.67dbA, SD=5.836) than noise in the corridor (M=53.99dbA, SD=5.532 and M=54.80 dbA, SD=5.576), t (178) =5.361, p<.001 and t (142) =5.199, p<.001. For the Bell 63 and Bell 64, there were no significant difference between noise in the corridor and noise in nurse team station.

39

AMBIENT ENVIRONMENT QUALITY: LIGHTING The light level measured in the south team station was 237 lx vertical.

Table 6. Lighting levels in patient rooms

Based on the Lighting for Hospitals and Healthcare Facilities standards

Measurement direction on the patient’s bed

Illuminance level (lux) KUMC, Room #7 Window Orientation: 326° NW

Illuminance level (lux) KUMC, Room #30 Window Orientation: 89° E

Looki ng forward

62

98

2011, P.27.20), the light levels in the patient rooms, during all three

Looki ng toward window

321

687

scenarios when patient is sitting on bed looking forward, are higher

Looki ng forward

86

132

Daylight + General lights

Looki ng toward window

414

897

Daylight + all lights (LEDs) on

Looki ng forward

402

420

Looki ng toward window

1091

N.A.

recommended by the Illuminating Engineering Society (IES, 2011, P.27.16 ), the nurse station has optimal light levels for conducting work tasks (237 lx > 200 lx recommended by the code for vertical target viewed by the general population). Based on the IES standards (IES,

than the recommended values for watching TV (50 lx vertical). When the general lights are on, the light levels in Room 30 is sufficient for reading but Room 7 needs more light for reading (compared to the 100 lx recommended by the standard for general population, 25-65 years old and 200 lx for seniors). When all the lights are on, the light

Daylighting Only

levels are sufficient for examination (200 lx recommended by the standard for 25-65 years old) in both rooms (Table 6).

41

AMBIENT ENVIRONMENT QUALITY: VISIBILITY AND ACCESSIBILITY

BELL 63 VISIBILITY AND ACCESSIBILITY

LOW

HIGH

The pattern of visibility and accessibility were analyzed with the software â&#x20AC;&#x2DC;Depth Map Xâ&#x20AC;&#x2122; using Visual Graph Analysis (VGA). In order to conduct the visibility analysis, a set of square tiles were laid on the floor plan of each hospital unit. The software analyzes the relationship of each tile to adjacent tiles and sequentially to distant tiles (Haq & Luo, 2012).

For this study only the integration value was calculated to identify the overall visibility and accessibility conditions of each unit, because this value is most relevant to the human movement or human visibility.

The visibility of each unit is visually demonstrated with a color coded map through the software.

Figure 11a. Bell 63 Visibility

Figure 11b. Bell 63 Accessibility

Integration values for visibility represent

Integration value for accessibility represents the global

the global visibility

of the whole unit.

accessibility from one point to the rest of the system.

The higher the integration value the

The higher the integration value the easier the space is

more visible the space is from the rest

to reach from the rest of the unit. All the red spots in

of the areas. All the red areas in the map

the map represent the higher integrated areas. These

represent the more visible areas. On the

areas are the most accessible from the rest of the units.

other hand, the dark blue areas are the

On the other hand, the dark blue areas are the most

more obscure areas of the floor plans.

disintegrated areas of the floor plan, and therefore less accessible than the other spots.

43

UNIT 64 VISIBILITY AND ACCESSIBILITY

Table 7 demonstrates the average visibility and

LOW

HIGH

CA 5 VISIBILITY AND ACCESSIBILITY

Figure 12a. Bell 64 Visibility

Figure 13a. CA 5 Visibility

Figure 12b. Bell 64 Accessibility

Figure 13b. CA 5 Accessibility

LOW

HIGH

accessibility of the four units, the nurse stations, nurse alcoves, and corridors.

Bell hospital has higher visibility comparing to Cambridge hospital, which means Bell hospital is more visually connected at the sitting height than Cambridge hospital. Among the four units Bell 63 has the highest visibility and accessibility compared to the other four units. On the other hand, CA 5 has the lowest visibility and accessibility compared to the other four units. Better accessibility means staff can easily move from different parts of the unit in Bell 63, when compared to the other four units.

45

CA 6 VISIBILITY AND ACCESSIBILITY LOW

HIGH

Figure 14a. CA 6 Visibility Table 7. Average Visibility and Accessibility

Visibility

Accessibility

Figure 14b. CA 6 Accessibility

Average Integration value NS Integration value NA Integration value Corridor Unit Visibility Range Integration value NS Integration value NA Integration value Corridor Unit Accessibility Range

Bell 64 6.56

CA 6 5.94

Bell 63 8.53

CA 5 6.103

6.55

5.79

8.027

5.78

7.178

6.237

8.47

6.21

5.766 9.42-1.77 4.75

5.1008 8.38-2.47 4.83

7.119 10.84-2.84 5.75

5 8.25-2.51 4.84

5.61

5.725

6.51

5.57

5.74

5.88

6.52

5.86

4.59 7.83-2.124

4.77 8.037-2.431

5.444 8.57-2.93

4.71 7.91-2.46

The corridors, nurse stations and nurse alcoves of unit 63 are the most visible and most accessible areas from the rest of the unit when compared with the other three units. The extended â&#x20AC;&#x2DC;zâ&#x20AC;&#x2122; shaped layout of CA5 and CA6 produced less visible spaces compared to the straight layouts of Unit 64 and Unit 63. Among these four units, the visibility and accessibility of nurse stations, nurse alcoves and corridors of CA5 are the lowest.

47

Figure 15a.

Nurses’ behavior mapping data of interaction with other persons in CA6

BEHAVIOR MAPPING ANALYSIS Interaction with multiple persons

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Figure 15b.

Nurses’ behavior mapping data of nurses’ interaction in CA6

1,764 points. Among them in CA5, 489 points; in CA6, 664 points; in unit 63, 537 points; in unit 64, 671 points were documented for

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various nurses’ activities.

Work Related Interaction

The images below showed how various activities distributed in space using CA6 as an example (Figure 15a-d).

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49

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Figure 15d.

Nurses Behavior Mapping data of different activities in CA6

Figure 15c.

Nurses Behavior Mapping data of different posture in CA6 Care Coordination Sitting Standing

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51

BEHAVIOR MAPPING ANALYSIS: NURSE INTERACTIONS Figure 16a. CA 5 Nurses’ Frequency of Interaction with Others

Figure 16b. CA 6 Nurses’ Frequency of Interaction with Others

The nurses of all four units interact most frequently with peer nurses.

In the Bell units nurses have a higher frequency of interaction with fellow nurses and patients compared to nurses of the Cambridge units. In Bell 64, about 44.3% of the nurses interact with fellow nurses, which is the highest among the four units. CA6 has about 36.8% interaction between peer nurses, which is the lowest among

Figure 16c. Bell 63 Nurses’ Frequency of Interaction with Others

Figure 16d. Bell 64 Nurses’ Frequency of Interaction with Others

the four units. On the other hand, the frequency of nurse interactions with doctors, nutritionists, and therapists in the CA units is higher compared to the doctor/nurse interaction in the Bell units, which may be attributed to the close proximity of the team room to the nurse stations (Figure 16a-d).

In addition, in the CA units nurses interact with the patient family members more often when compared to the Bell Units. It appears the well-designed designated lobby lounge area, consultation rooms and the conference rooms are promoting the additional interactions.

53

Figure 17a. CA 5 Nurses’ Frequency of Interaction by types

BEHAVIOR MAPPING ANALYSIS: NURSE INTERACTIONS (CONT)

Figure 17b. CA 6 Nurses’ Frequency of Interaction by types

In the Cambridge units the frequency of work related to interaction is higher compared to those of Bell units.

Nurses of CA5 (45.5%) and CA6 (44.2%)

had more

frequent work-related interactions when compared to the work-related interactions of Bell 63 (39.9%) and Bell 64 (29.3%). By contrast, the rate of social interaction is higher in the units of Bell compared to the units of Cambridge (figure 17a-d).

On the other hand, the Bell units have more social interaction compared to Cambridge. The rate of social

Figure 17c. Bell 63 Nurses’ Frequency of Interaction by types

Figure 17d. Bell 64 Nurses’ Frequency of Interaction by types

interaction in Bell 63 is 16.3%, in Bell 64 is 11.5% whereas in CA5 it is 5.5% and in CA6 8.9%.This fact also supports our previous findings that the nurses of the Bell units interact with the patients and fellow nurses more than the nurses of Cambridge. The small size, compact layout and higher inter-visibility of the Bell units probably promotes more encounters and spontaneous social interactions than the Cambridge units. Simultaneously, better visibility ensures prompt peer support in Bell when it is needed. In Cambridge the less visible spaces produce less interaction.

When the nurses interact in Cambridge they tend to solve work-related issues.

55

BEHAVIOR MAPPING ANALYSIS: SPACE UTILIZATION Figure 18a. CA 5 Nurses’ Frequency of Space Utilization

The behavior mapping data demonstrates

Nurses of the progressive units visit the team

that nurses use nurse stations most often

room, corridors, medication room, lounge,

during their work days. In Bell 63, nurses

and break room more frequently compared

spend almost 40% of their time in the

to the nurses of the ICU units. Nurses of CA6

nurses stations (Figure 18a-d). ICU nurses

use the team room about 9.2% and the break

visit the patient rooms more often than

room about 3.2% of their total utilization of

the progressive nurses, perhaps due to the

space, whereas the nurses of Bell 64 use the

higher acuity of their patients. In terms of the

break room (6.8%), perhaps due to the fact

ICUs, both units have similar visits to patient

that Unit 64 does not have any team room for

rooms, but the new design of Cambridge

communication and the break room is used

allows nurses to utilize the alcoves more

as a team room for care coordination. The

often, hence providing closer contact with

design and adjacency of team rooms to nurse

patients and family. For instance, nurses of

stations in CA5 and CA6 encouraged the

CA5 use the nurse stations less frequently

frequent use of these collaborative spaces,

(30.9%) compared to the nurses of Bell 63

which can lead to better care coordination

(39.9%). Rather the nurses of CA5 use the

and inter-disciplinary communication. We

nurse alcoves more (10.8%) compared to the

noticed the reduced frequency of patient

nurses of Bell 63 (8.3%).

room visits in CA6 compared to Bell 64.

Figure 18c. Bell 63 Nurses’ Frequency of Space Utilization

Figure 18b. CA 6 Nurses’ Frequency of Space Utilization

Figure 18d. Bell 64 Nurses’ Frequency of Space Utilization

57

BEHAVIOR MAPPING ANALYSIS: NURSE ACTIVITIES Figure 19a. CA 5 Nurses’ Frequency of Activities

Figure 19b. CA 6 Nurses’ Frequency of Activities

The behavioral mapping data demonstrate that nurses in all four units conduct tasks on documentation and care coordination most frequently. Nurses of the ICU units (CA5 and Unit 63) had a higher frequency of patient care activities compared to the nurses of unit 64 and CA6. 11.5% of activities of the nurses in Bell 64 are related to looking for certain things, where as the nurse of CA 6, CA5 and unit 63 spend respectively 6.1%, 1.6% and 5.2% looking related activity

Figure 19c. Bell 63 Nurses’ Frequency of Activities

Figure 19d. Bell 64 Nurses’ Frequency of Activities

(Figure 19a-d).

59

BEHAVIOR MAPPING ANALYSIS: NURSE ACTIVITIES (CONT)

Figure 20a. CA 5 Nursesâ&#x20AC;&#x2122; Value added Activity Vs. Non-Value added Activity

Figure 20b. CA 6 Value added Activity Vs. Non-Value added Activity

Figure 20c. Bell 63 Value added Activity Vs. NonValue added Activity

Figure 20d. Bell 64 Value added Activity Vs. Non-Value added Activity

VALUE-ADDED ACTIVITIES AND NON-VALUE-ADDED ACTIVITIES In order to fully understand where the nurses were spending the majority of their time, a further analysis of value-added versus nonvalue-added tasks was completed. A non-value-added task was considered a task that took unnecessary time to complete due to distance traveled, such as delivering or retrieving an item. A valueadded task was a task essential to the well-being of the patient, such as patient care, care coordination, documentation, assessment of vitals, family care, or administration/teaching. Nurses in both the units of Cambridge are involved in more value-added activities compared to the nurses in the Bell units. When comparing the two progressive units, 78.4% activities of nurses in CA6 are value-added activities, whereas 70.3% activities of the nurses of Bell 64 are valueadded activities. When comparing the two ICU units, 84.2% activities of nurses in CA5 are value-added activities, whereas 82.3% activity of the nurses of unit 63 are value-added activities (Figure 20a-d).

61

BEHAVIOR MAPPING ANALYSIS: NURSE ACTIVITIES (CONT)

Figure 21a. CA 5 Nurses’ Posture

Figure 21b. CA 6 Nurses’ Posture

Nurses of the progressive units (CA6 and Bell 64) walk more often than the nurses of the ICU units (CA5 and Bell 63). On the other hand, nurses of the ICU units do more tasks while standing than the nurses of other two units. 30.7% of the posture of the nurses of unit 64 are walking, which is the highest compared to the other three units. The high frequency of looking and retrieving activities in Bell l64 could impact the higher frequency of walking. On the other hand, 47.2% of the posture of the nurses in CA6 are sitting, which is

Figure 21c. Bell 63 Nurses’ Posture

Figure 21d. Bell 64 Nurses’ Posture

the highest compared to the other three units (Figure 21a-d).

It seems that the distributed supply rooms allow CA6 nurses to have less frequent walking for looking and retrieving supplies.

63

WALKING DISTANCE COMPARISON BY UNIT TYPOLOGY

WALKING DISTANCE USING PEDOMETERS

The RNs in CA6 (M=7062, SD=2369) walked significantly more than Bell 64 (M=5941, SD=1675), t (113.597)=3.057, p<.05 (Figure). On average, the Bell 64 nurses walk about 2.81 miles and the CA6 nurses walk 3.34 miles. The RNs in CA5 (M=5098, SD=1392) also walked significantly more than Bell 63 (M=4030, SD=1171), t (138)=4.877, p<.001 (Figure). On average, the Bell 63 nurses walk about 1.91 miles and the CA5 nurses walk 2.41 miles (Figure 23).

The actual walking distance was further analyzed by capturing the steps taken per shift using pedometers. In total, 276 sets of walking distance data were collected. Among them, 264 sets were for RNs and 12 sets were for float nurses. We kept the 264 sets of all RN data for final analysis, 124 sets in the progressive care units (60 sets in Bell 64 and 64 sets in CA6) and 140 sets were collected in intensive care units (66 sets in Bell 63 and 74 sets in CA5).The

WALKING DISTANCE COMPARISON

BY SHIFTS

Overall, RNs walked more during night shifts (MD=318 steps). Interestingly, there is no clear difference of walking distance between day shift and night shift nurses in Bell 64 (MD=15), while a statistically significant difference in CA6 (MD=1490, t(46.975)=-2.63, p<.05). The difference can be contributed to the more linear and linear layout of the decentralized nursing unit in CA6, requiring nurses to walk more to check multiple patients who require closer surveillance during the night.

Another interesting finding is that nurses in CA5 walked less during the night shift, perhaps due to the fact that they only have 1-2 patients, the nursing alcove allows them to stay close to the assigned patients for visual surveillance, while Bell 63

results showed that RNs in the progressive care units (Bell 64 and

nurses walked slightly more during night shift, although the differences were not

CA6) walked significantly more (M=6519 steps, SD=2130) than

statistically significant (MD= -357 and MD=216 correspondingly, Figure).

nurses at ICU units (Bell 63 and CA5, M=4595 steps, SD=1395), t

Figure 23. Nursesâ&#x20AC;&#x2122; walking distance by shifts and units.

(207.654)=8.567, p<.001. On average, the ICU nurses walk about

Walking Distance by Unit Types

2.18 miles and progressive care nurses walk 3.10 miles (Figure 22).

Daily Shift Average

4145

4919

3929

4595

4030

5000

5276

6000

5098

5950

5935

5941

6519

6317

7000

7062

Figure 22. Walking Distance by Unit Types

Night Shift Average

7807

Total Average

4000 3000 2000

Total average

1000

Progressive care units

0

ICU

CA6

BELL64

CA5

BELL63 65

WALKING DISTANCE COMPARISON

BY EXPERIENCE LEVELS Overall, less experienced nurses walked more than more experienced nurses (MD=407 steps). In CA6, Bell 64, and Bell

Table 8. Average Shift Distance Walked Based on Experience

63, less experienced nurses walked more than experienced CA6

nurses (MD= 513 steps and MD=180 steps, and MD=322 steps,

BELL64

CA5

BELL63

OVERALL

respectively), although the difference is not statistically significant.

However, in CA5, less experienced walked less than more experienced nurses (MD=-293 steps) (Table 8).

During day shifts in CA6, Bell 64, and Bell 63 units, less experienced nurses walked more than experienced nurses (MD=

Distance

Less

More

Less

More

Less

More

Less

More

Less

More

(steps)

Exp.

Exp.

Exp.

Exp.

Exp.

Exp.

Exp.

Exp.

Exp.

Exp.

7214

6701

6030

5850

5022

5315

4191

3869

5642

5235

6694

5689

6326

5521

5093

5492

4163

3835

5762

4896

7631

8435

5544

6379

4982

3817

4204

3974

5560

6023

Total Average

1005 steps, MD=805 steps and MD=328 steps respectively), while during night shifts the trend was reversed (MD= -804 steps and

Day Shift Average

MD=-835 steps, and MD=-463 respectively). It seems that more experienced nurses in progressive care units and Bell 63 tend to walk more during night shift to cover the unit to make sure things

Night Shift Average

are under control. Interestingly, less experienced nurses in CA5 walked significantly more than experienced nurses during the night shifts (MD=1165 steps).

67

PATIENT SATISFACTION AND OUTCOMES

PATIENT SATISFACTION Table 10. Hospital-wide patient satisfaction comparison

In terms of various aspects of patient experience, we didnâ&#x20AC;&#x2122;t have access to the unit level data. Based on the

Hospital-Wide

data for the entire hospital during one month before

after

ADMISSION

61

72

ROOM

68

78

more detailed unit-level data analysis with longer time

MEALS

69

42

periods will help us understand whether the positive

NURSES

88

94

TESTS TREATMENTS

79

90

VISITORS FAMILY

68

90

PHYSICIAN

91

93

DISCHARGE

87

92

ISSUES

82

94

OVERALL ASSESSMENT

84

91

and one month after the new Cambridge A building

are surveys conducted by Press-Ganey, a company established in

was occupied, there is a clear improvement in all

the late 1970s with a mission to improve the patient experience by

aspects with only exception of meals (Table 10). A

average rating and the percentile rank of the units were compared

change was specifically related to the move to the new

before and after moving to the new Cambridge A tower. The

facility.

differences in values for each element was analyzed to determine if a significant change in perception could be observed.

Figure 24. Patient satisfaction comparison between

Bell 63 and CA5 before and after move Patient Satisfaction (Press Ganey)

After moving to Cambridge A Tower, the mean score of CA5 overall

93 92

hospital ratings have improved from 91.5 to 92.2, which is an increase

91

of 0.8 percent, and the mean score of CA6 also improved from 89.3

89

to 90.8, which is an increase of 1.7 percent. It is worth noting that

87

90 88

Table 9. Unit-level Press Gancy comparison Before (1/1/2017-12/31/2017)

the control units Bell 63 and Bell 64 both had decreased patient

BH63-TIC

satisfaction ratings (91.9 to 89.2 and 90.8 to 89.9 respectively, see Table 9, Figure 24 and Figure 25). It showed that the change of environment contributed to the improvement of patient experience in the Cambridge Tower. Since we didnâ&#x20AC;&#x2122;t have access to monthly data and individual patient level data, we are not able to conduct statistical analyses such as t-tests and logistics regression for the odds ratio.

(10/28/2018-11/3/2018)

before

One of the most commonly utilized tools for seeking patient feedback

providing feedback from patients regarding their hospitalization. The

(7/1/2016-6/30/2017)

Figure 25. Patient

CA5

Before (1/12017-12/31/2017) Press Ganey

between Bell 64 and CA6 before and after move Patient (Press Ganey) PatientSatisfaction Satisfaction (Press Ganey) 91 90.5

Percentile Mean

Rank

Responses

BH63-TIC

39.2

82

20

73

NEI (CA5 before

92.2

99

94

89.9

91

260

90.8

96

440

Mean

Rank

Responses

BH63-TIC

91.9

99

13

NEI (CA5 before

91.5

98

satisfaction comparison

After (1/1/2018-12/31/2018)

Percentile

BH63-TIC Rena/Organ Transplant

90.8

97

136

BH63-TIC Rena/Organ Transplant

NEP (CA6 Before)

89.3

88

319

NEP (CA6 Before)

90 89.5 89 88.5

Before (1/1/2017-12/31/2017)

BH64- Renal/Organ Transplant

CA6

69

PATIENT OUTCOMES

FALL RATES

Patient falls occurring during hospitalization can result in serious and even potentially life-threatening consequences for many patients (NDNQI, 2016). Both unassisted and assisted falls are included in fall rates.

INFECTIONS RATES (CDIFF, HAPI, CLABSI)

Central Line-Associated Bloodstream Infection (CLABSI) rate is calculated by the number of CLABSI divided by Central Line Days times 1,000. For CLABSI, there were very few incidents in all units. Clostridium Difficile (C. Diff) rate measures the events of C. Diff and it is related to hand hygiene and the overuse

Table 11 reported the average number of incidents for CALBSI, C. Diff, HAPI, and Falls

of antibiotics. The development of hospital acquired pressure injuries (HAPI)

per month using the data from May 2016 to May 2017, and April 2018 to September

places the patient at risk for other adverse events and increases resource

2018. In addition, the total number of these adverse events during an equivalent time

consumption and healthcare costs (NDNQI, 2018). HAPI measures the number

period before and after moving into the Cambridge A Tower was compared side-

of patients who acquired (developed) a new pressure injury after admission

by-side in Figure 26, 27a-d (6 months for CALBSI, C.Diff, and Falls and 3 months for

to the hospital.

HAPI). For CALBSI and C.Diff, Bell 63 ICU had higher total incidents and average monthly rates during the period after the move than during the period before.

On the contrary, Bell 64, CA5, and CA6 all reduced the CALBSI and C. Diff total incidents and monthly rates. For HAPI, Bell 63 had lower monthly rates and overall

Table 11. Unit-level patient oucome comparison

incidents during the after-move period than before. However, Bell 64, CA5 and CA6

CALBSI

had much higher HAPI rates after the move. For falls, the two Bell units have similar

Before A f t e r Before A f t e r (monthly (monthly (monthly (monthly average) average) average) average)

rates before and after the move, but the CA5 and CA6 have dramatically reduced rates during the after-move period (50% and 58% respectively).

BH63 In addition, after moving to the new building, CA6 had lower C. Diff rate than the control unit (Bell 64), while the other three measures are similar. CA5 has lower CALBSI and C. Diff rates but higher HAPI and falls than its control unit (Bell 63) after the move.

C. Diff

ICU BH64 CA5 ICU CA6

HAPI

Falls

Before (monthly average)

A f t e r (monthly average)

Before (monthly average)

A f t e r (monthly average)

0.17

0.33

0.58

1.17

2.75

2.33

0.33

0.33

0.25

0.00

1.08

1.00

1.25

1.67

1.58

1.33

0.33

0.00

2.50

0.83

1.75

3.67

1.33

0.67

0.17

0.00

0.67

0.33

1.75

1.67

3.17

1.33

71

PATIENT OUTCOMES

Figure 27b. HAPI Before and After move to Figure 27a. Falls Before and After move to 16

INFECTION (CDIFF, HAPI, CLABSI) AND FALL RATES

14

14

12

12

10

10

8

8

HAPI

Falls

-m ove to Patient outcomes before and after move to Cambridge A Tower Cambridge A Tower

6

6

4

4

2

2

0

BH63 ICU

BH64

CA5 ICUC

A6

0

BH63 ICU

BH64

CA5 ICUC

A6

Figure 27c. CALBSI Before and After move to

Before (average per month) CA6

Before (average per month)

CA5 ICU BH64

Before (average per month)

CALBSI

Cambridge A

16

Cambridge A

BH63 ICU Before (average per month)

Cambridge A

3.5

Figure 27d. C. Diff Before and After move to

3 2.5

15

2 1.5

10

1

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00

Average per month

Cambridge A

20

5

0.5 0

BH63 ICU

BH64

CA5 ICUC

A6

0

BH63 ICU

BH64

CA5 ICUC

A6

Figure 26. Total incidents of falls, HAPI, C. DIff, and CALBSI in four units.

Figure 27a-d. Before and after-move comparison of total

Before (6 month)

incidents and average incidents per month for falls, HAPI,

After (6 month)

CALBSI. and C. Diff in the four units.

Before (average per month) After (average per month)

73

HAND HYGIENE RATES

Table 12. Unit-level hand hygiene compaliance comparison based on hospital report

The impacts of the unit layout on hand hygiene were evaluated at two

BH63

CA5

Month

ICU

BH64

ICU

CA6

Dec-16

92%

93%

93%

93%

(CA5 and CA6) by comparing with the hand hygiene compliance rates

Jan-17

93%

98%

98%

98%

during the six months before the move. The concurrent hand hygiene

Feb-17

94%

96%

96%

96%

Mar-17

95%

95%

95%

95%

Apr-17

96%

92%

92%

92%

on-site observations and evaluate whether visibility and accessibility of

May-17

94%

84%

84%

84%

the hand hygiene stations in these units affect the frequency.

Apr-17

98%

95%

95%

95%

May-18

93%

93%

93%

93%

spanning from December 2016 to May 2017 and April 2018 to August

Jun-18

94%

86%

86%

86%

2018, the average hand hygiene compliance rates for Bell 63 ICU (95%)

Jul-18

96%

87%

87%

87%

is higher than CA5 ICU (92%), and the average hand hygiene compliance

Aug-18

98%

94%

94%

94%

Sep-18

97%

95%

95%

95%

94%

93%

91%

93%

96%

92%

94%

93%

95%

92%

92%

93%

levels. The first level was to track the changes of hand hygiene compliance rates during the six months after moving into the Cambridge A Tower

compliance rates of the two matching units at the Bell Hospital were also analyzed as control units (Bell 63 and Bell 64). The second level was to compare the frequency of hand hygiene activity during the one-week

Based on the data provided by the University of Kansas Hospital

rates for CA6 (93%) is higher than BH 64 (92%), although the difference was not statistically significant (Table 12). When comparing the hand hygiene compliance rates before- and after-move to the Cambridge A tower, CA5 ICU has higher rates after the unit moved from the Heart Hospital (94% versus 91%), while CA6 retained similar compliance rates (93% versus 93%), although the differences were not significant. It is noted that the sample size is rather small, which might create bias in

Before-Move Average After-Move Average Total Average

the analysis. A longitudinal study is recommended for understanding the long-term effect of the physical environment on hand hygiene compliance.

75

& ?8VHUV?DVXWHU?'HVNWRS?&DPEULGJH 1RUWK 5

LOCATION OF HAND HYGIENE STATIONS

Visibility and Accessibility of Hand Hygiene Stations Visibility

Accessibility

To evaluate the impacts of the visibility and accessibility Unit 64

of hand hygiene stations on hand hygiene activities in

Nurse:

Figure 28c. CA 5 Hygiene Stations and Occurrences

map, accessibility map, and the hand hygiene stations were developed (Figure 28a-d). The visibility and accessibility of hand hygiene stations were calculated

Unit Name

these units, the superimposed images of the visibility Unit 63

5(675220 5(675220

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The comparative chart (Figure 29) shows the hand

8.77

9.284

9.027

6.487

5.98

6.233

hygiene stations of Bell 63 are the most visible and

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of CA5 are the least visible and accessible of the four

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using Depthmap X and shown in the Table 13 below: Table 13. Unit-lvel comparison of hand hygiene stationsâ&#x20AC;&#x2122; visibility and accessbility

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Figure 28d. CA 6 Hygiene Stations and Occurrences

Figure 28b. Bell 64 Hygiene Stations and Occurrences

18

7 3 5 331 6 30 10

21 16 25 23

16 20 15

16

13

20

25

9 11 3213

29 36

19

11

9 152

4 13

5 8

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13 9

14

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16 11

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29

77

Bell64, CAM 6, Bell 63, CAM 5 Bell 64

CAM 6

Bell 63

CAM 5

Total Amount of Activity

ACTUAL OBSERVED HAND HYGIENE BEHAVIORS ON SITE

Behavior tracking helped to capture time and motion by recording locations and

HH Occurrences

duration of various nursing activities including hand washing behavior. Data was collected in two consecutive weeks in both the morning shift and the afternoon shift by a group of students.

The observers followed one volunteering nurse for a continuous hour and recorded activities using task type, task category, and location. With the participation of 10 nurses, the number of total activities recorded in unit 64 is 312, including 60 hand hygiene occurrences, whereas in Unit 63 total activity was 232, including 34 hand hygiene occurrence.

Similarly, in Cambridge 6, number of total activities were 246, including 25 hand hygiene occurrences, whereas in Cambridge 5 total activity was 298, including 52 hand hygiene occurrence. Locations of hand hygiene occurrences of Bell 64 and Bell 63 are identified in Figure 28a & 28b, similarly the red numbers in Figure 28c & 28d demonstrates the hand hygiene occurrences of Cambridge 5 and Cambridge 6.

In Bell 63 the total number of hand hygiene occurrence was 34, however the Bell 63 unit contains only 24 hand hygiene stations. On the other hand in Cambridge 5 total number of hand hygiene occurrence was 52 in 40 hand hygiene stations (Figure 30).

Number of HH Stations

0

100

200

Figure 30. Unit-level comparison of observed hand hygiene activities versus the number of hand hygiene stations

300

The data demonstrate that Bell 64 contains the lowest number of hand hygiene stations (23) , although the hand hygiene occurrence rate in this unit is 19%. In the other hand, CA5 contains the highest numbers of hand hygiene stations (40) but the hand hygiene occurrence rate in this unit is 17% . CA6 contains 32 hygiene stations, but the hand hygiene occurrence rate in this unit is 10%. In Bell 63 the hand hygiene rate is 15%, and number of hand hygiene stations are 24. The results demonstrate that the number of hand hygiene occurrences do not depend on the number of hand hygiene stations. The overall visibility of the two units of the Bell hospital is higher compared to the overall visibility of the two units in the Cambridge hospital.

Additionally, both the average visibility (9.027) and average accessibility (7.602) of the hand hygiene stations in the two units of Bell are higher compared to the average visibility (6.233) and average accessibility (5.931) of the hand hygiene stations of the two units in Cambridge. Therefore, the hand hygiene occurrences in the two units of Bell hospital is higher than the hygiene occurrences in the two units of Cambridge.

79

PATIENT ROOM POE Based on the Center for Healthcare Design standardized patient room POE toolkit, for the 23 EBD goals, the average score of CA5 is 24% higher than Bell 63 (4.41 vs. 3.33) and the average score of CA6 is 18% higher than Bell 64 (4.56 vs. 3.73).

Categories

EBD Goals

CA5

Bell 63

CA6

Bell 64

Patient safety

01. Improve mobility and reduce falls

4.00

4.80

4.80

4.40

Patient safety

02. Reduce risk of injury

4.67

3.00

4.33

3.00

Patient safety

03. Reduce risk of contamination

5.00

4.67

5.00

4.56

Patient safety

04. Improve hand sanitization

4.00

5.00

3.00

5.00

Patient safety

05. Provide safe delivery of care

4.50

5.00

5.00

4.50

Worker safety & effectiveness

06. Provide efficient delivery of care 3.91

4.73

4.82

4.09

Worker safety & effectiveness

07. Improve communication 5.00

3.00

5.00

4.00

Worker safety & effectiveness

08. Improve staff health 3.50

3.00

3.50

3.50

Worker safety & effectiveness

09. Improve job satisfaction 4.67

2.67

5.00

3.00

Quality of care & patient experience

10. Reduce patient pain, stress, anxiety, and delirium

5.00

1.75

4.75

3.25

Quality of care & patient experience

11. Enable & enhance patient sense of control 3.50

2.50

4.00

3.50

Quality of care & patient experience

12. Improve patient engagement 5.00

4.00

5.00

4.00

Quality of care & patient experience

13. Improve patient satisfaction 4.33

3.00

5.00

3.33

Quality of care & patient experience

14. Improve family presence and engagement in patient care

4.00

1.00

4.33

3.33

Quality of care & patient experience

15. Improve comfort 5.00

2.33

5.00

3.67

Quality of care & patient experience

16. Reduce noise 5.00

2.00

5.00

4.00

17. Respect privacy

Patient room evaluations were done using both a

Quality of care & patient experience

4.50

4.00

4.50

4.50

standardized POE toolkit and the interviews with staff.

Organizational performance 18. Ensure durability

NA

NA

NA

NA

PATIENT ROOM EVALUATIONS

Table 14. Patient Room POE

Organizational performance 19. Improve air quality

NA

NA

NA

NA

Organizational performance 20. Provide a secure environment

4.67

3.33

4.67

3.33

Organizational performance 21. Enable change readiness/ future-proofing

3.50

3.50

4.00

2.00

Organizational performance 22. Enhance sustainability

NA

NA

NA

NA

Organizational performance 23. Provide return on investment (roi)

NA

NA

NA

NA

Average

4.41

3.33

4.56

3.73

81

STAFF SUGGESTED DESIGN IMPROVEMENT

STAFF SUGGESTED PATIENT ROOM IMPROVEMENT (CA 5 & CA6) 1.

The patient rooms are not standardized; some rooms are much larger than others, especially the ones at the corners of the bends, which makes the room layout less consistent across the unit;

2. Lack of counter space; 3. Scanner is hard to reach and the cable is too short; 4. It would be nice to have ceiling lifts in every room.

Currently, only four rooms have ceiling lifts. The Figure 31a.

facility team have to be called in every time to move the motor to the rooms that need lifts.

5. The boom in CA5 seems unnecessary. As long as there is a movable monitor, it would be fine. The boom is less mobile when you have a lot of wires attached to it anyway (Figure 31a); 6. There are multiple tracks on the ceiling: boom arm, ceiling lift track, curtain, IC hook. The ceiling mounted IV can sometimes get in the way when the

Figure 31b.

nurses try to move the hook or ceiling lift (Figure 31b); 7. There is a conflict between the location of the supply cart and the computer. Nurses frequently hit their heads when trying to get supplies from the cart. Maybe change the computer to be wallmounted instead of on the arms (Figure 31c).

Figure 31c.

83

STAFF SUGGESTED PATIENT UNIT IMPROVEMENT Overall staff are satisfied with the aesthetics of the units and the (CA 5 & CA6)

adjacencies of supply rooms to each team hub. They also had some suggestion to further improve the design.

1.The curvilinear shape and the bend seems to create a barrier for continuous visibility in the unit. Staff found it hard to see the call lights on the top of patient rooms from nurse stations or from the alcoves. It can potentially increase nurses’ walking distance.

2.One of the team rooms could use lower partitions for better visibility. For instance, the north team room is used mainly by the therapists and can remain with translucent partitions. The south team room is mainly used by nurses and it can use low partitions for better visibility and nurse teamwork.

3.The nurse station desk is closed on one end can make it harder for nurses and unit clerks to get to patient rooms.

4.There are only two public restrooms on the north end of the corridor. For patients who are assigned to the south end, their family members have to travel long distances to use the bathroom. There is only one staff bathroom on the south side of the unit, while three staff bathrooms are on the north side. Staff sometime have to travel long distances to use the bathrooms, and the staff bathrooms need door codes to guarantee staff use only.

5.The break room is well-designed, however it is a bit far removed from the patientcare area, and sometimes nurses will have their meals in the south team room instead to stay close to their patients. The current page system only displays the room number and the initial of the patient. For nurses to see the full information, they have to check the computers to see the details for patient-safety considerations.

Adding a computer in the break room can help nurses use the break room without

NURSE MANAGERS’ AND NURSES’ INTERVIEWS

being concerning about the access to patient information. distance to use the bathrooms sometime. And the staff bathrooms need door codes to guarantee for staff use.

85

INTERVIEWS WITH UNIT MANAGERS AND A SAMPLING OF NURSING STAFF SUMMARY Semi-structured interviews with the four unit managers and a random sample of awareness interviews with between nine and fourteen nurses on the four units were used to collect anecdotal data about the perceptions of how the units operated on a daily basis, the environmental quality of the units, and how the design of units could be improved. The unit managers emphasized that each unit design must be matched with specific operational and staffing strategies to insure that positive patient outcomes and nurse satisfaction were maximized. All the managers were satisfied with the ways their own unit layouts and designs created a positive care model. The managers in Bell Units 63 and 64 thought the compact central cores, square or elliptical floor plates, and even distribution of nurse stations contributed to efficient operations and allowed nurses to match daily assignments with a variety of home bases. Their primary concerns in Units 63 and 64 were the small size and nonstandardized configurations of the patient rooms, the noise created in the compact core design, and general lack of storage and family-support spaces.

Nurses on Bell Unit 63 were positive about the size of the unit, the compact central arrangement of nurse stations and support core, and ability to communicate effectively with their colleagues. The compact unit layout contributed to good surveillance of patient rooms and other nurses but also caused excessive noise and crowding, especially during rounds. The small patient room sizes, non-standard layout, and lack of storage were concerns of the nursing staff. The extent and configuration of computers throughout the unit were evaluated positively. Similar opinions were expressed by nurses in Unit 64 as those in Unit 63, except the former were not concerned about small patient-room size or non-standard room configurations.

Nurses on Cambridge 5 were positive about the patient-room sizes and standardized configurations, placement and number of computers throughout the unit, the aesthetic quality of the unit, and the location and design of the team room and support areas. They felt they were prepared for the transition to the new design and attributed the success of the unit to daily staffing assignments to maximize nurse efficiency with appropriate home base locations. The most consistent concerns were focused on the unit size for critical -care patients, the length and isolation of the two corridors, the visibility difficulties caused by the corridor bends, and the sense

The unit managers in Cambridge 5 and 6 had been part of the design team and

of isolation, both along the length of the unit and between the Cambridge Tower

were well-prepared to integrate their staffsâ&#x20AC;&#x2122; operational models at the time the

and the main hospital campus. The perceptions of nurses on Cambridge 6 paralleled

units opened. They recognized the new design must be matched with careful daily

those in Cambridge 5 in most areas, although they were not as concerned about

staffing assignments to take advantage of the emphasis on the alcove stations, the

the overall unit size. They did express concerns about the length of the corridor and

nurse stations and the team rooms. They were most positive in their assessment of

there was only two public restrooms on the north end of the corridor. For patients

the size and configuration of patient rooms, the extent and placement of computers

who are assigned to the south end, their family members have to travel long distance

throughout the unit, the family accommodations, and the overall aesthetic quality

to use the bathroom.

of the spaces. They felt the units design had improved the lighting quality, reduced noise, and enhanced exterior views from the environments in the Bell and Heart units. Their primary concerns were focused on the length of the units, visibility difficulties caused by the bends in the floor plates, and the isolation of the staff along the corridor lengths and across the opposing corridors.

87

UNIT MANAGER INTERVIEWS Interview with Katie Mayer, Unit Manager for Bell 63, Bell Hospital, KU Health System Conducted by Hui Cai, 11 October 2018, 3:30 PM

Katie Mayer has been the unit manager of Unit 63

The unit is implementing a new call light system and each

between Units, 61, 63, and 65.

(Transplant ICU) for two months.

She has worked

nurse wears a locating badge to monitor positioning in

loosely associated with the nursing staff in each unit.

amount and compactness of space.

on the unit as an RN since 2008. The unit design and

the unit. Cell phones are used as a messaging system as

The unit is small and compact, which is good for

central area is the biggest deficiency.

material finishes have been in place since 2008. Before

well, especially for urgent situations and assistance calls.

efficiency and nurse coordination. There is one clean

rooms are the same size or configuration, which limits

becoming the unit manager she worked in various

The unit is fairly small, so much of the communication

supply in the unit and one remote in the â&#x20AC;&#x153;garage.â&#x20AC;?

patient placement and nurse assignments. There four

patient-care roles and is familiar with the nursing and

between staff is done by visual contact. The majority of

There is a need for a larger unit clean supply area. Cart

large rooms on the corners.

care models that have been used over the ten-year

communication is face-to-face.

storage and in-room supply systems are maintained by

The toilets are too low to the floor, although there

materials management.

is ample space around each toilet for patient care.

period. Two years ago a LEAN study was conducted to

The medical team is

implement a series of operational changes, especially in

Because of the small unit size and the configuration

the supply chain and materials management processes.

has not changed in ten years the work-related and

Patient privacy can be improved at the patient door,

This system is fully implemented in the unit.

social patterns are tight and long-term.

Storage in the Also, not all

Families are allowed to overnight in recliners, although

Work and

especially for light intrusion from the hall at night and

social relationships are fluid. Room assignments are

controlling light throughout the day. The door is good

There are fourteen single-bed rooms on the unit.

generally made by three zones within the unit, although

for nurse monitoring.

The patient mix is comprised of 2/3 medical and 1/3

some nurses do split remote rooms based on patient

access to showers.

transplant cases. No acuity index is used to determine

therapies or acuity.

staffing assignments, although higher ratios are used

Unit 63â&#x20AC;&#x2122;s most pressing design feature is the limited

there are no special facilities for family or visitors.

Patients would like personal

Noise is somewhat a problem because the unit is

based on therapy regimes. There are some bone

Assignments of work stations are at the discretion of

compact and sound carries throughout the entire area.

marrow patients in the mix as well. The average daily

each nurse, depending on room assignment and patient

Patients are close to each nursing area, which is positive

census is 12.6 to14 beds. The unit is almost always full.

condition.

for the staff, but intrusive to patients and family.

The use of the room alcoves depends

on nurse preference.

Orientation of new nurses is

There are typically seven RNs, one charge nurse, and

dependent on previous work experience and a fluid

Katie has seen a centralized unit design (Unit 46) but

two aides in each twelve-hour shift in the unit. The

process. The basic spatial requirement is the presence

has never worked in a centralized environment. Her

typical staffing ratio is two patients per nurse.

of two computers for students and preceptors to work

impression of Unit 46 is that it limits nurse visibility and

in tandem on each case.

causes patient isolation.

The typical work day consists of a group report and duty change meeting at 7:00 AM and 7:00 PM

Inter-professional communication is done face-to-face

followed by an initial rounding to determine patient

at the morning rounds and electronically in all other

assessments. Medication, vitals and assessment rounds

instances. A medical team has a home base in each

are conducted each hour.

unit, although ICU medical teams split their caseloads 89

UNIT MANAGER INTERVIEWS Interview with Miki Mahnke Unit Manager for Bell 64, Bell Hospital, KU Health System Conducted by Hui Cai, 12 October 2018, 2:00 PM

provides fast circulation to get around the unit. Until the new

unit, and patients come from various regions. In addition, the

call lights system is installed, there are some blind spots and it

LOS for patients is generally long. It will be difficult for the

is difficult to see call lights. Overall, Miki likes the design of the

family to stay in a hotel for two weeks. It is important to be

Miki Mahnke has been the unit manager for more than five

A typical day of the unit consists of a morning report at 7:00

unit because the size of the unit is good, which creates a sense

able to accommodate family in the patient rooms.

years. She started in Unit 64 as an RN about thirteen years

AM followed by patient assessments at 8:00 and a unit huddle

of intimacy. The nurses are not so spread out.

ago when the unit was first opened. Even though the unit

at 8:30.

shares the similar philosophical care culture with other units

and 10:00 followed by a safety huddle in the center core at

More break room space is needed for staff. She prefers to

the front. She gets interrupted a lot.

in the University of Kansas Hospital, this unit has a unique

10:30. New orders, triage care and new-patient evaluations

preserve the break room for nurses. There is no space for

The flexibility to dim the lights is good. Having access to

organizational culture that is warm and welcoming. There is

occur at 11:00. A medical transplant huddle occurs at 11:30.

students to put their belongings and training. Typically seven

natural light is important. Compared to the break room in the

a good sense of community. They have also ranked as tier

Nurse take their lunches between 10:00 AM and 2:00 PM.

nursing students will cover per shift. They also conduct nurse

CA units, the break room in Bell 64 doesn’t have access to

one in nurse satisfaction. There are rotation nurses who sign

Patients are discharged between 2:00 and 4:00, and the daily

tasks but they wear school uniforms. Most of the formal inter-

natural light. In terms of patients, they all have some access to

up as new graduates and get to try out different units. At

improvement huddle occurs at 3:30. Patients are continued

professional communication happens at the break room

natural light, but not a lot. We do try to open the blinds during

the end of that year when they have fulfilled their one-year

to be admitted between 4:00 and 7:00, and night shift reports

during huddles. Informal and impromptu inter-professionals

the day to promote the healthy balance of circadian.

commitment they choose which unit they would like to work

are accomplished between 7:00 and 8:00 PM. Ten WOWs

communication happen at bedside or the nurse station.

on Typically, five or six of the nurses choose UNit 64, which is

are deployed throughout the unit. Nurses will use the same

a nice compliment to the culture of the unit.

one throughout the day except for nurses who are in charge

Compared to other units (Unit 66), the doors in Unit 64 have

for huddles and meetings. Currently the huddles happen when

of isolation patients. Nurses also use VoiP Cisco phones and

glass panels which allow good visibility to patient rooms.

some nurses are eating breakfast. It is important for nurses to

Bell 64 has a fluid matrix staffing model, since the capacity

Sonitors nurse locators.

The unit provides a healthy balance between privacy and

have uninterrupted break time.

tends to flex a bit. There are 24 beds and they typically staff

Miki feels there is more face-to-face communication on this

visibility, but the privacy curtains that touch the bed seems

A staff healing garden is a nice concept, but it is hard to

with eight nurses. The staffing ratio is anywhere between one

unit. Three NPs are embedded in the unit and four pharmacists

an infection control issue (the position of curtain track and

implement since nurses have very tight schedule, only 30

to two or one to four based on patient acuity. New kidney

are specially trained in the unit. Having their offices in the

the bed placement needs more coordination). The blinds in

minutes for a break. It is hard to leave the floor, as nurses feel

transplant patients are typically very sick patients and require

floor facilitates more face-to-face interactions. Face-to-face

each nurse alcove allow nurses to peak into the patient rooms

they need to be close to their patients. Most nurses don’t leave

close monitoring, so they’re staffed 1:2 or 1:1 depending on

is preferred, even though people also talk on the phone.

without being too disruptive. The most frequently used daily

the unit even during lunch breaks. Nurses take great pride to

their condition. Three-fourths of Unit 64 patients are surgical

Nurses are encouraged to use the patient-room alcoves and

supply in each patient room in addition to the centralized

keep their patients safe.

patients and fall under the transplant surgery umbrella.

to sit close to patients if patients are in critical condition or at

supply throughout the unit. The bedside supply is a result of a

Some have had other complex abdominal surgeries such

high fall risk rather than at the front or back stations for faster

Lean re-engineering initiative. The clean supply room is large,

When nurses need help, they will first look for peers then call

as pancreatic cancer. There are also about 1/3 or 1/4 of the

response to all lights. The central station is a bit isolated and

good in size.

for help. The light allows nurses to see if a nurse is in the room,

medical patients who have kidney disease. The typical length

hard to see the call lights. The preference of where to sit is also

of stay for a liver transplant patient is 11 days; for a kidney

related to personalities.

Medication rounds are completed between 8:30

transplant patient the average length of stay is 5 days. Two-

The double doors are loud. The manager’s office is too close to

Areas for improvement include the provision of separate places

the central monitor in the front station allows them to see who Patients and family are satisfied with the environment. The

is in the room. Currently, this is the only approach to see which

rooms are not overly large, but they are comfortable. There

nurse is in which room. Otherwise, they will have to call nurses’ phones to find out.

thirds of the patients are on heart monitors. The average

The layout is very conducive to communication and co-

is a love-seat and recliner in the room to allow family to stay

census is 23.4. The total staffing is about 40 nurses.

awareness. The center core corridor through the middle

overnight with the patients. This is a very successful transplant

91

UNIT MANAGER INTERVIEWS Interview with Adam Meier, Unit Manager for 6th Floor Progressive Care, Cambridge Tower A, KU Health System, Conducted by Hui Cai, 17 October 2018, 12:30 PM

Adam Meier has been the unit manager of the

throughout the unit, and assignments attempt to avoid

served by direct visual connections.

Progressive Unit on the 6th floor of Cambridge A

room separations where possible.

Patients seem satisfied with the environment. Nurses

Daily staffing is made on specific patient mix and

since the unit opened. He has worked at KU as an RN

There are eight to ten RNs and three to four care

chart at either the alcove or nurse station, depending

treatment needs. The huddle room and buddy system

for six years. He was a member of the planning and

assistants on each twelve-hour shift.

on patient needs and nurse preferences. No WOWs are

help to foster daily staff contact and communication

used by the nursing staff, but are used by the medical

patterns.

design team that worked with the architect to devise the final unit configuration and room layouts. Before

The typical day begins at initial check-in at 7:00 AM,

becoming the unit manager at 6 Cambridge he worked

followed by a safety huddle at 8:00 AM.

in the Heart ICU unit.

The new design process was

assessments take place between 8:00 and 10:00, with a

The recessed corridor lights were a major design feature

guided by a LEAN process that was focused the two

multi-disciplinary huddle at 9:30. Afternoon rounds are

to eliminate harsh lighting conditions for patients. The

primary goals of creating a patient/family centered

completed between 2:00 and 4:00, with a management

lighting system provides better ambient conditions

work concept and an environment that minimized a

improvement huddle occurring at 4:00. Huddles are

than those in the Heart Hospital.

clinical look and feel.

held in the central team room.

The process was designed to

Meds and

improve the efficiency of the material handling and supply chain and decreasing nurse walking.

Supply

and student groups.

The next design process should consider the challenges presented by the long plan configuration and curve.

The design supports on-boarding and the â&#x20AC;&#x153;At the elbowâ&#x20AC;?

A Voalte iPhone is issued to each nurse at the shift

education model. Nurses are paired with students and

carts and in-room computer systems were two specific

change

electronic

require dual computers and charting areas. A majority

design innovations. A complete LEAN documentation

communication system. Face-to-face communication

of the teaching takes place at bedside to involve the

package was produced, which Adam will pass along to

is the preferred method among all staff members, with

patient in the process.

the POE team as point of reference for the operations

70% of interactions occurring on a personal level.

which

comprises

the

primary

of the unit.

The primary positives of the design is the careful layout

All nurses on 6 Cambridge moved from the old

The environment supports the team concept and seems

of the patient areas, the great views from each room,

progressive unit in the Heart Hospital.

to foster good communication patterns. The team

and the family-focused waiting and support areas.

room is especially supportive of the multi-disciplinary

The primary negative is the long unit layout and the

The typical nursing ratio for progressive patients is

concept on the unit. The nursing staff have a monthly

visualization issues created by the curving plan. The

three patients per nurse, with lower acuity ratios of four

team meeting in the conference room.

unit is big and the support functions at the far ends are

to one. The average LOS on the unit is 3.5 days. The

removed from the central activities and patient-care

average daily census is twenty-six. Staffing assignments

There are visualization challenges because of the curved

are made through a combination of geographic

floor plate and length of the unit. This is especially a

proximity and nurse competency for specific acuity

problem in limiting views of the room nurse-call lights.

levels and diagnoses. There is a buddy system in place

The rooms close to the central nurse station are best

zones.

93

UNIT MANAGER INTERVIEWS Interview with Stacy Smith, Unit Manager for 5th Floor ICU, Cambridge Tower A, KU Health System, Conducted by Hui Cai, 12 October 2018, 3:00 PM Stacy Smith has been the unit manager of the neurology

Each nurse wears a Hill Rom locator badge and personal

facilitate the team integration model. Faculty was on

and efficiency of the space.

ICU at KU since 2000. She has been in the same care

phones are equipped with a Voalte communication

the unit in 9 Heart. All non-patient-care functions are

Nurse on-boarding is better in 5 Cambridge because

unit for eighteen years. Prior to her assignment on 5

system. Texting is the preferred method of electronic

located at the two ends of the unit, which limits total

rooms are closer together and alcoves provide a

Cambridge A, she was assigned to Unit 15 in the original

communication.

integration and communication.

convenient area to work in tandem. The increase in

Bell Hospital, then Unit 61 in the renovated Bell, and

system is being installed in the unit.

The configuration of the supply/storage rooms are

computer access and space here is good for training and

finally in the 9th floor in the Heart Hospital. She has

There is no preference for communication protocols.

well-designed at each of the two unit ends. Both have

education programs. Paired assignments with students

experienced four distinct unit designs and nursing station

There is mix of face-to-face and electronic. There is an

identical layout and size. Med rooms have entries on

and preceptors last 280 hours.

configurations, although the basic care model and

emphasis on adaptability in the unit, since the team and

each corridor side. The primary problem is that the

nursing protocols have remained constant throughout

work processes have been in place over a long period of

supply areas are remote from the patient-care zones in

Staffing model hasnâ&#x20AC;&#x2122;t changed from 9 Heart. Unit 15

this period. A LEAN protocol is currently implemented in

time. No major changes in communication patterns were

the center of the unit. Most nurses use the patient room

was a centralized station design for seven ICU and eight

the unit to conform to a hospital-wide system.

seen after the move from 9 Heart.

and bedside storage systems.

progressive patients. Unit 61 was a centralized unit with

5 Cambridge seems better for room visibility and

Patient placement and nurse assignments are critical to

pods and alcoves dispersed within the space. Heart 9

5 Cambridge is a neurology ICU with a majority of

assignment because rooms are evenly and closely

make this unit operate safely and efficiently. Each nurse

had four pods at the corners with alcoves at each room.

cases of head and neck cancer surgery.

spaced and the unit design is flexible.

The primary

is given personal options for use of stations or alcoves

Stacyâ&#x20AC;&#x2122;s personal preference was the layout in unit 61.

difference with 9 Heart is that 5 Cambridge is very long.

for patient care. Patient visibility is good because of this

Cambridge 5 is much more generous in the amount of

flexibility in nurse station choices. Flexibility of the unit

space, more flexible and contains more beds.

There are

twenty-eight single-patient rooms on the unit, and

A new emergency communication

the rooms are uniform in size and configuration. The average LOS is 4 to 4.5 days. Average daily census

Many

is dependent on surgery schedules, with twenty beds

implemented to acquaint the staff with the new

pre-move

strategies

and

pretests

were

Patient privacy is OK based on a wide range of curtain

The unit is in the process of adding patient monitors.

typically occupied Tuesday through Friday, and eight

configuration and layout.

options and door position. Toilets are private which is a

Monitors can only be accessed from the central station

to twelve on the weekends.

the beginning was the length of the unit compared to

plus for patient privacy.

and rooms, which limits knowledge throughout the unit in

Overall average is seventeen per day.

9 Heart. The entry security and charge nurse locations

Nurse staffing varies between seven and fifteen RNs

were determined based on this pre-move training.

Lighting in the unit is good and flexible in terms of

The duplicate support spaces at each end of the unit is

each shift. There is a unit secretary at the front station

The central team space is a critical feature of the design.

control and variety of systems in patient rooms and staff

good, although the unit is very long. Storage space has

and one charge nurse at the primary central station.

It fosters clear coordination and communication patterns

support areas.

reached its limit. The ideal arrangement would be two

Typical staffing ratios are two patients per nurse,

among all caregivers. The team space is well-situated

Noise is a problem at night because of monitoring and

fourteen-bed units that could operate independently

although some special ratios are necessary due to

and designed, although it can be crowded and difficult

alarm systems. Overall noise levels are good in the unit.

but be combined as needed.

acuity and therapy protocols. Nurses are assigned by

to maintain acoustic privacy.

geography as well as specific acuity and treatment

Inter-disciplinary communication is based on formal

Patients and families are generally very pleased with the

protocols. There is not a formal buddy system, but the

protocols from 9 Heart, although the team room concept

overall ambient conditions and aesthetics of the unit and

unit has a long-term cohesion.

is different. Providers have home bases in the unit to

room design. Staff use feedback to improve comfort

The primary concern from

layout is the biggest advantage of the design concept.

critical situations. More monitoring stations are needed.

95

NURSE INTERVIEWS Bell Unit 63 Fourteen Interviews Completed between October 29 and November 2, 2018

Does the current design support your work flow and

Does the unite support the social environment and

efficiency?

team concept of nursing?

Does the current layout promote good patient care?

Have you experienced other units? What are your

Almost all nurses thought the design of Unit 63

The compact size and central focus of the support

only negative comments were concerned with the small

Most of the nurses had floated in other ICUs throughout

supported the nursing processes and were efficiently

areas promoted a sense of closeness and constant

patient room sizes for critical access and procedures

the hospital.

arranged. They liked the central location of the nurse

communication. Colleagues were close by and within

and the non-standard room arrangements.

the environment in Unit 63, primarily because of its

stations and proximity to all the support rooms. They

easy access. Sometimes the compact arrangement

liked the compact and small size of the unit, the

became congested when residents rounded and the

How does the current arrangement affect your health

nurse stations surrounding an accessible support core.

proximity of the nursing areas to the patient rooms,

corridor became the central focus of communications.

and well-being.

The comments about the Heart units were positive,

overall thoughts about Unit 63?

This was viewed positively by almost all the nurses. The There was a strong preference for

compact layout and the central organization of the

and square configuration of the unit. The two primary

although the Unit 63 staff thought the larger size and

complaints were the non-standard layouts and sizes of

Does the current arrangement promote a balance

Most nurses felt there was a good balance between

distances in the Heart units were a problem. Those who

the patient rooms and the inability to see through the

between privacy and patient surveillance?

convenience of the compact unit size and distribution

had worked in Cambridge did not like the long, linear

central service area.

of supplies and support spaces. The close proximity

layout and the limited visibility issues along the length

Surveillance is very good for the nursing staff, but does

to patients and visual access to other staff members

of the unit. The Unit 63 nurses preferred a combination

Does the current unit design support your work-

cause concerns for patients and visitors. The nursing

tended to reduce stress of isolation. Walking distances

of centralized and alcove stations that offered the

related interactions with the other staff members?

areas are in direct proximity to the patient rooms, which

were not a problem and most nurses felt walking

possibilities to work in a variety of configurations with the patient mix.

means that noise from the corridors and support areas

promoted good health. Some nurses mentioned the

The nurses were uniformly positive about the layout

cause problems for the patients. Also, patient data is

need for better lighting and more colors on the walls.

and size of the unit to promote group cohesion

easily viewed by visitors, and there is little space for

Some felt the rooms could be arranged to give better

and communication.

sensitive conversations to occur in the unit.

access to groups of nurses interacting at the patient

It is easy to find and visually

communicate with other staff members. They like the

bed and better family accommodations.

flexibility of having both centralized corner stations

Does the current layout promote easy charting and

and room alcoves to fit different patient needs and

multitasking?

acuity levels. The square unit layout made distances equal and predictable. The unit was limited in terms

This was seen as positive by most nurses, especially

of storage space, but the â&#x20AC;&#x153;garageâ&#x20AC;? off the unit was

in terms of the access to supplies and number and

accessible and no major problem.

location of computers. The issue of visitor access to computers and supplies was a concern.

97

NURSE INTERVIEWS Bell Unit 64 Nine Interviews Completed between October 22 and October 26, 2018

Does the current design support your work flow and

Does the unit support the social environment and

Does the current layout promote easy charting and

How does the current arrangement affect your health

efficiency?

team concept of nursing?

multitasking?

and well-being.

The nurses were positive in their assessment of

The layout fostered a positive response to supporting

The number and distribution of computers throughout

Unit 64 was evaluated as having a positive effect on

the ways work flow and nurse efficiency were

social interactions among the staff. There was some

the nurse stations and patient rooms was viewed as

nursesâ&#x20AC;&#x2122; health. The amount of walking was perceived

accommodated in Unit 64. They felt the distribution

concern about finding colleagues in the central

positive and fostered the ability to chart and multitask

as having the correct balance in Unit 64. Some nurses

of the three primary nurse stations gave a wide variety

hallway. The staff liked the way the unit is divided

from almost any location on the unit. The unit was

had worked in larger units that required excessive

of alternatives for nurse to work in proximity to their

into two smaller circular components to break up the

perceived to have a compact and efficient distribution

walking, which was a major cause of stress and

assigned patients and at the same time maintain visual

overall size of the unit. The unit seemed to be the

of support space and data-input points. There was

fatigue. The staff liked the size of Unit 64 compared

connections to their colleagues. They liked the circular

right size when broken into two equal spaces rather a

not a lot of comment on the use of the alcove stations.

to the larger units in the hospital.

flow of the unit and the centrality of the core support

single, long space.

Does the current layout promote good patient care?

Have you experienced other units? What are your

spaces. There was some concern about the congestion created by student rounds and losing contact with

Does the current arrangement promote a balance

staff in the central hallway.

between privacy and patient surveillance?

overall thoughts about Unit 64? care routines. The walking distances from nurse

Most of the nurses has worked in units similar in

Does the current unit design support your work-

The three separate nurse stations foster close

stations, supply rooms and patient rooms were

layout to Unit 64 and preferred a centralized nursing

related interactions with the other staff members?

proximity and visibility to patient rooms and also

satisfactory. Some difficulties were expressed in

concept. Those who had worked in Heart and

decrease the noise generated at any given station.

accessing supply and medications in the central

Cambridge preferred Unit 64 because of its compact

The nurses were almost uniformly pleased with the

Privacy curtains and patient doors can be used to

hallway as well as losing contact with other staff

core and reasonable walking distances to patient

work interactions supported by the layout in Unit 64,

increase or decrease privacy and visibility levels.

members. Overall, the unit was evaluated as having

care and support areas. They preferred a centralized

and they focused on the multiplicity of arrangements

an efficient and relatively compact layout and

concept because it promoted better communications

allowed by the three distinct nurse stations in relation

arrangement of activities.

and visibility throughout the unit.

The nursing staff felt Unit 64 promoted good patient-

to patient assignments. The central core was viewed positively as a means to support staff communication patterns.

99

NURSE INTERVIEWS Cambridge Unit 5 Eleven Interviews Completed between October 29 and November 2, 2018

Does the current design support your work flow and

Does the unite support the social environment and

Does the current layout promote easy charting and

How does the current arrangement affect your health

efficiency?

team concept of nursing?

multitasking?

and well-being.

The staff members were pleased with the general layout

Again, the team room was mentioned as the most

The room layouts and number of computers throughout

Most nurses expressed the concern that the unit was

of the patient rooms and support areas, especially the

positive aspect of the unit to promote social cohesion

the unit were viewed positively by almost all the staff

very large for an ICU. The additional walking distances

central team room. The quality of the space and finishes

and communication. The sense of isolation in such a

interviewed. The flexibility of the unit design was

were not a major drawback and in some instances were

were positive elements of the unit. The most consistent

large and linear unit was the primary concern expressed

appositive aspect of the responses.

There were

viewed as positive for staff health. The primary concern

concerns expressed by the nursing staff were the

by the staff. There were suggestions that the unit core

concerns expressed about the isolation of the staff

was a sense of isolation in such a large unit was a cause

length of the floor plate and the size of the overall unit

should be opened to allow visual and social interaction

areas at the ends of the unit rather them being placed

of stress. Additional time is spent on the unit searching

to accommodate an ICU. The staff had prepared for

across the unit as well as down the corridors.

in a central core.

for colleagues and support staff.

the move to a large, linear unit, and careful staffing

nurses felt an ICU should have a clear sense of visual

assignments on each shift contribute to the success of

connections and a central focus.

Does the current layout promote good patient care?

Have you experienced other units? What are your

Does the current arrangement promote a balance

Again, the room layouts and size were viewed positively

between privacy and patient surveillance?

in terms of patient care. The primary concern was the

Most of the staff had experienced units in Bell and Heart

inability to view across the unit from the nurse stations

and preferred a centralized nurse station arrangements

room

and corridors. Visibility and distance were concerns

with shorter walking distances. They preferred smaller

The

about maintaining a sense of care coordination and

ICU sizes and centralized layouts. The length of the

quick response times in emergencies.

Cambridge 5 layout and the curved corridors were

The

overall thoughts about Cambridge 5?

the unitâ&#x20AC;&#x2122;s operations.

Does the current unit design support your workrelated interactions with the other staff members?

Patient

surveillance

is

dependent

on

the

The nursing staff prepared for the move to Cambridge

assignment and placement along the corridor.

5, and the success of the unit is due in large part to the

sight lines become difficult at the corridor bends.

close interactions of the staff on each shift. There were

Patient privacy is good and the rooms have a variety

a number of concerns expressed about the feeling of

of privacy provisions built into the design. Privacy for

isolation and visual separation, especially in emergency

nurse work is not good at the alcoves.

mentioned as concerns in the current design.

situations. The nurse stations and team rooms were mentioned as the primary areas where communication and staff interaction were facilitated.

101

NURSE INTERVIEWS Cambridge Unit 6 Eleven Interviews Completed between October 22 and October 26, 2018

Does the current design support your workflow and

Does the unite support the social environment and

efficiency?

team concept of nursing?

Does the current layout promote good patient care?

Have you experienced other units? What are your

Most staff were pleased with the way the unit supported

Most nurses preferred this arrangement, especially the

arrangement, and overall quality of the patient rooms.

Centralized units can be much noisier than Unit 6.

workflow. The success of the unit was the way daily

team room concept. The large number of computers

Large patient baths and patient lifts are improvement

Most nurses preferred a decentralized nurse station

room assignments were matched with nurses. This was

and updated communication technology were positive

from other hospital units.

arrangement because it gave more choices of home

planned before the move to Unit 6. Nurses chose their

elements of the design. The unit can be isolating, both

good for improving bedside care and ease of access

bases and access to patients.

home bases each day based on assignments and acuity

within the floor itself and in relation to the main hospital

to supplies. Some concern was raised about the room

caused more walking. The primary concerns for Unit 6

of patients. Support areas could be closer together and

campus.

sink being moved closer to the hall door.

was the corridor bend and the sense of isolation due to

avoid long distances. The bend in corridor is a problem

depending on daily staffing assignments.

overall thoughts about Cambridge 6?

Patients and family are complimentary on size,

Finding colleagues is sometimes difficult,

The Heart Hospital

unit size and linear configuration.

How does the current arrangement affect your health

for visibility and connection to other staff.

Does the current arrangement promote a balance Does the current unit design support your work-

Room supply carts are

and well-being.

between privacy and patient surveillance?

related interactions with the other staff members?

The key to staff health is the way the daily assignments Privacy for patients is good. The operable blinds at

are matched with patient mix and room locations. The

The team is a positive factor in enhancing staff

the alcoves were a positive aspect of the room design.

bigger unit can cause a sense of isolation and difficulty

interaction.

The number and placement of so many

Patient surveillance can be a problem depending on

in accessing colleagues.

computers is a positive aspect of interactions with

the nurse home base assignment. Visibility down the

difficulties in visual connections and surveillance of

The corridor bend causes

staff. Higher degree of reliance on technology to

corridors and across the unit are limited.

patient rooms.

communicate. Good connections to patient areas.

Daily assignments of rooms and home bases are the

Does the current layout promote easy charting and

key to making interactions work. Extra distances to

multitasking?

support areas and lack of cross-corridor access routes is a negative. The lack of visibility throughout the unit

The number and location of computers and other

was a concern.

technology was mentioned by most nurses. The ability to choose home bases based on daily assignments was a positive aspect of the design.

103

RESEARCH DESIGN AND GOALS

PART II

KU HEALTH SYSTEM INTERVENTIONAL PLATFORM AND SURGERY POE REPORT BACKGROUND Dramatic changes have occurred in the delivery of interventional care since the

SETTINGS

opening of the Bell Hospital in 1978.

Robotics, ambulatory care, interventional

imaging, and new surgical techniques have resulted in major changes to the facilities required to offer functional, safe patient care.

The new Cambridge A building

has provided the University Hospital with an opportunity to design interventional services space based on contemporary concepts and need.

RESEARCH DESIGN AND GOALS This evaluation focused on the analytical analysis of space utilization in the surgery and interventional imaging sections of Cambridge A, along with limited observation and interviews of staff. Due to the numerous modifications to the original spaces in the Bell Hospital, a comparison of the functionality of two environments was assessed to have limited value. Patient survey responses for care provided in these specific hospital areas were limited, resulting in the inability to integrate this input into the assessment.

SETTINGS The core of interventional service is located on the second and third floor of Cambridge A. Central Sterile and additional family waiting spaces are located on the first and basement levels. These floors are connected to the other hospital facilities via a two level pedestrian bridge linking Cambridge A across 39th Street to buildings on the south side of the street. The core of staff lockers and lounge spaces are located on the second floor of Cambridge A, shared with the Interventional Imaging service.

105

SURGERY

The third floor, and portions of the second floor, of Cambridge A are dedicated to surgical services. The primary procedures are cancer procedures performed by Neurosurgery, ENT, Orthopedics, and General surgery services. Support for other University Hospital cases are provided as needed, primarily on the weekends.

PREP/ RECOVERY AREA

The prep/recovery area is designed to “flex” during the day as workload volumes shifts from prep functions to recovery. There are 29 “universal” bays. Currently, two of the bays are dedicated to Cardiology for ultrasound procedures, and one room is mostly used as for equipment storage. There is one isolation room near the entry to

Facilities on the third level of the building include eleven operating rooms divided

the service, and one near the back, south side of the plan. Most of the holding rooms

into two pods, MRI, prep and recovery services, satellite pharmacy and laboratory

are designed with a sliding partition wall to allow nursing staff to manage care for

functions, administrative offices, sterile core services, and equipment storage. Three

two patients without entering the main circulation corridor.

of the operating rooms area focused on neurosurgery, with one room directly connected to the MRI (Figure 32).

During the most recent six month, 3,351 cases were performed in the eleven staffed operating rooms. Most of these cases were inpatients or same day admits. The complexity of procedures performed result in long procedure times, averaging almost three hours (Table 15).

The total departmental gross square footage assigned to this service is 47,464. This includes essentially all the third level, 80% of the staff support areas on the second level, and a small waiting area on the first floor. This result is a ratio of 4,300 DGSF

Figure 32. Cambridge A Tower Surgery department floor plan

per operating room. This is significantly high than typical referenced ratios of 3,000 – 3,500 DGSF per O.R. Several factors contribute to this higher ratio.

Main Surgery Suite Table 15.

Time Period: April-September 2018

Neuro Surgery

Cases

Minutes

Avg Case Time

2

219

110

926

216220

233

1

327

327

Otolayngology

1399

201541

144

Plastic Surgery

72

16432

228

General Surgery

8

876

110

939

143571

153

Trauma Surgery

3

265

88

Urology

1

153

153

3351

579604

173

Anesthesiology

Cardiology Flash Prep

Neurosurgery Orthopedics

Oncology Surgery

Total

Reception/Waiting

Administration

Assume Scheduled Days

Prep/Recovery

The inclusion of a MRI imaging unit. (Not included in the O.R. room count)

Cambridge A Surgery Volume

MRI

Sterile Core

•

Cases Per Day Staffed Rooms Cases Per Room Per Day

124 (April 1st - September 25th) 26.2

•

Dual circulation patterns with a semi-public corridor parallel to the internal operating room “sterile core” circulation corridor.

•

Inclusion of work space for anatomical pathology within the service.

•

A staff lounge/locker area larger than typical.

•

Underutilized space next to the service elevator at the north end of the floor.

11 2.4

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PREP/ HOLDING AREA

The prep/holding area is designed to allow flexible assignment of patient bays

Figure 34. Surgery prep/holding area

between pre-surgery preparation and post anesthesia recovery. A typical bay is 134 net square feet.

Observation and interviews with staff indicate that the bays

are appropriately sized for the care provided. During the initial occupancy of this area recovery patients were distributed throughout the available beds. The current practice is to consolidate recovery patients at the south side of the unit, with a bank of six rooms in the middle swinging as needed between prep and recovery care functions. Staff reported the consolidation of recovery provided efficiency and that family and patients traveling to the prep area did not have to pass by recovering patients that might be in discomfort.

A two-week sample of bed utilization found the peak demand for beds in this area was 16, occurring during the late morning period. The ratio of peak bed needs to staffed operating rooms is lower than for typical surgery suites, primarily due to the long case times and the resulting average of 2.4 cases per operating room (Figure 33).

Figure 33.

The original layout of the holding bay rooms was designed to have a primary staff and family zoning areas within the room, with the staff work area along the left side (facing) of the patient gurney, and family seating along the right side. The installation of the computer work station at the headwall resulted in the need to relocate the mobile supply cart to the right side of the room. This requires staff to frequently pass in front of the family to access supplies (Figure 34).

Computer workstations are in multiple locations including decentralized terminals between holding bays. Observation and staff comments indicate that the decentralized workstations are frequently used by medical staff in addition to nursing, making the terminal in the patient bay area an important backup.

A moveable partition between every two rooms is intended to allow staff to move quickly between patients if close supervision is required. This capability was not used during the limited observations in the area. Staff report periodic use for patient care in the recovery phase and more limited use in during preparation. Staff pointed out that this is a good feature to have when considering potential long-term changes in patient care needs over the life of the facility.

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Observations in the unit found that some conversations could be heard between bay areas, particularly if the moveable partitions were not fully closed. The overall sound levels in the unit fell into a low range. Sample reading in different locations

OPERATING ROOM SUITE

Figure 37. Operating room

show an average range between 55 and 66 decibels, with limited ability to discern conversations in the patient bays. This contrasts with Bell PACU North. Although the decibel readings were only slightly higher in north, there was not patient and family privacy in the recover pod areas. All conversations could be overhead in this unit.

The current staffing pattern for the unit is based on geographic assignments of staff to four to six adjacent patient bays (Figure 35). This limits the overall amount of staff walking. Storage and supplies were not identified as a major concern, although storage of gurneys was in the hallway area at the south end of the unit

Figure 35. Charting alcove

Figure 36.

One issue that was raised by staff was recent modification of the door to the soiled utility room. A combination lock was installed, requiring entry of a code to gain access.

The main surgical area is divided into two pods, with three operating rooms located at

Staff pointed out that this could present a potential

the south end dedicated to neurosurgery and eight O.R.â&#x20AC;&#x2122;s organized into a traditional

source for a fomite surface for infection transmission,

sterile core configuration in the center and north areas of the floor. Operating room

since staff could be carrying bed pans from patients with

#1 is immediately adjacent to the MRI, with direct, secured, access to the MRI from

Cdif or other infectious diseases (Figure 36).

the operating room

Four patient toilets are located near the north and south

The size of the operating rooms ranges from 648 nsf to 770 nsf, with an average

ends of the holding areas. Staff would prefer the rooms

size of 676 square feet. The rooms were designed to provide â&#x20AC;&#x153;universalâ&#x20AC;? flexibility

more evenly distributed among the patient beds.

for a large variety of procedures (figure 37). The current focus in Cambridge A is

Staff report that the four consultation rooms located

with neurosurgery, ENT, orthopedic and general (cancer) surgery. The universal

near the public waiting areas are effectively used by

configuration of the typical room allows the separation of the primary sterile field

surgical staff for post procedure consultation with family

area from the entry and circulation patterns in the rooms.

members. The waiting area is small for the service. A key concept in this area is the use of the first floor waiting

A significant exception to this overall concept are some of the ENT cases, particularly

and cafeteria for additional waiting, utilizing cell phones

those using the Da Vinci robotic unit. Many of these patients, after initial anesthesia

for update and contacts to return for consultation. It

induction, are rotated 45 degrees toward to main circulation zone.

was unclear how effective this concept was working for

access with the robotic unit at the head of the patient but creates potential conflicts

the service.

with good sterile technique when non-robotic, sterile surgeries are performed at the

This allows

patient neck (Figure 38).

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STAFF INTERVIEWS Interviews with staff found overall satisfaction with the configuration and functionality of the operating rooms. Among the comments and issues identified were the following:

• The need for a third surgical light, particularly in the rooms assigned to ENT and where two surgical teams may be working on the patient at the same time.

• Questioning of the functionality of the second power boom in the operating room. Staff interviewed indicated that most of the time it was not used and was an impediment to circulation around the operating room table.

• The difficulty in opening and the closing times of the doors from the perimeter corridor into the operating rooms. The option of sliding doors was suggested as potentially easier to use and could create less air turbulence within the O.R. • The location of the two scrub sinks outside the neurosurgery operating rooms #2 and #11 were cited as problems due to staff using these sinks rather than the sink inside the neuro core area. Staff noted that this results in staff entering the operating rooms through the patient entry and into to non-sterile area of the room.

• It was suggested that a small, potentially folding, metal shelf would be beneficial Figure 38. Operating room set up with Da Vinci unit for ENT cases

The HVAC system is designed to provide “laminar,” unidirectional air flow across the surgical field. Again, in the ENT room it is not clear the impact of rotating the operating room table has on this concept.

It was also

next to the anesthesia primary work area to allow discarding of items used by the anesthesia team. Currently these items are frequently placed on the anesthesia machine, the circulating nurse work desk, or other locations.

• A small alcove area along the corridor at the entry to the operating room suite would remove gowning activities along the corridor area.

noted that the Da Vinci control unit and other equipment were place near the return air duct in the O.R., potentially compromising the air flow concept.

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CT

Interventional Imaging

Rad/Fouro Special Procedure

Shared Lockers/Lounge

Holding/Post Obs. Special Procedure

Shell

Figure 39. Cambridge A Tower Interventional services floor plan

INTERVENTIONAL SERVICES

Table 16. Six-month sample of workload of procedures

There are two special procedure angiographic rooms with biplane imaging capability, one CT, and one fluoroscopy

OVERVIEW Interventional

imaging

rooms,

and

twelve

holding

bays. One shell room is located adjacent to the two angiographic rooms for future expansion. An MRI is

imaging services

provided

include angiography, CT, fluoroscopy and

located adjacent to the service but is not included in its scope of services. Two holding bays are held for use by MRI and other services (Figure 39).

other procedures is space on the second floor of Cambridge A. The core of the service

A six-month sample of current workload Indicate that the four major procedures performed in the service are

occupies 14,882 departmental gross square

neuro arteriogram, lumbar punctures, percutaneous

feet of space

biopsies and spinal diagnostic procedures (Table 16).

Typical weekday workload averages 10-12 cases per day, with Wednesday averaging the highest volume at 12 cases.

CNC Evaluation CT Guide Needle Placement CT Spine Cervical W/Contrast IR Ablation IR Arteriogram Body IR Arteriogram Neuro IR Aspiration/Drain IR Body Embolization IR Bone Marrow Biopsy IR Central Venous Catheter IR Gastrostomy IR Injection IR Kyphoplasty/Vertebroplasty IR Liver Biopsy IR Lumbar Puncture IR Neuro Embolization IR Percutaneous Biopsy IR Sclerotherapy IR Spinal Diagnostic IR Venous Diagnostic/Intervention Joint Apir/INJ Major W Fluoro LT

44 9 1 7 3 363 46 3 8 53 17 12 48 1 396 20 246 7 183 8 1 115

Figure 40. Interventional services prep/recovery room

The departmental gross area per diagnostic and procedure rooms is 3,700. This ratio is high due to the shell room included in the service and the capacity of the holding area for other services. The two special procedure rooms are sized at 622 net square feet and 625 respectively.

Figure 41. Intenventional imaging prep/recovery bed utilization rate

The prep/recovery area is organized into a “ballroom” configuration, with open-bay rooms wrapped around a central nursing station. There is one holding room design for isolation care. The average bay size is 122 nsf. These holding rooms do not have the movable partitions seen in the surgery area. This results in the ability to keep the supply cart on the “staff” side of the patient bed (Figure 40).

The current mix of patient includes outpatients and inpatients primarily from the Cambridge A inpatient units. Patients are prepped in the holding area, with critical care patients typically moving directly from the inpatient unit to the procedure area.

Inpatient may also be moved directly from the procedure area back to the inpatient unit. A two-week sample of patient bed use throughout the day indicate ample current capacity (Figure 41). This area could accommodate the conversion of the shell space into an additional procedure rooms.

Figure 42. Interventional radiology procedure room

The size of the procedure rooms appears appropriate for the mix of procedures (Figure 42).

Our team

observed a neuro angiography case involving twelve medical, anesthesia, nursing and other personnel in the room.

The shared control room between the two

procedure rooms provided sufficient area for staff supporting each room without interfering with each other.

We were unable to schedule staff interviews to obtain feedback regarding the performance of this unit.

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INSTITUTE FOR HEALTH + WELLNESS DESIGN

THE UNIVERSITY OF KANSAS HEALTH SYSTEM POE REPORT