Hospital Observation Report

HOSPITAL O B S E R V AT I O N S

AUSTIN FERGUSON

|

SUMMER 2017

|

CLEMSON UNIVERSITY

TABLE OF CONTENTS 1.0 | Goals + Objectives 2.0 | Observations 2.1 | Observation 1 - Brigham and Women’s Hospital Radiation Oncology 2.2 | Observation 2 - Brigham and Women’s Hospital Radiation Oncology 2.3 | Observation 3 - Boston Children’s Hospital Technology 2.4 | Observation 4 - Boston Children’s Hospital Emergency Department 2.5 | Observation 5 - Boston Children’s Hospital OR Mock-Up Simulation 2.6 | Observation 6 - Boston Children’s Hospital Clinical Laboratory 3.0 | Overall Evaluation 4.0| Appendix

1.0 GOALS + OBJECTIVES

1.0

Goals + Objectives VERIFY the functionality and practicality of certain design ideas that we have studied in class by observing the ideas in the hospital setting

IDENTIFY key functional areas within each unit that is observed to understand crucial design requirements

UNDERSTAND how care providers utilize their space and how current spaces should adapt to ideal efficiencies and operations

EDUCATE myself about topics observed, but not discussed in class, to further understand what works and does not work within a specific unit

2.0 O B S E R V AT I O N S

DATA DATA

TX Suite

Main Rad. Onc. Department

Radiation Oncology department at Brigham and Women’s

2.1 | OBSERVATION 1

Brigham + Women’s Hospital Radiation Oncology Department June 1, 2016

Intro My first observation took place at the Radiation Oncology department at Brigham and Women’s Hospital. I was fairly familiar with the department prior to my observation because I assisted with the design of a renovated TBI vault and an overall department masterplan during my internship with Payette in the summer of 2015. However, during these projects my time spent on-site was very limited and what I knew about the department was mainly gleaned from plan drawings at the office. So this observation gave me the opportunity to see if some of the assumptions the project team made about the department were accurate.

The Radiation Oncology department is fragmented within Lower Level 2 of the hospital which poses a very unique and complicated situation for the staff and patients. The separation is the result of placing a LINAC where it fit best; disjointed from the main department. I was a slightly disappointed by this condition because it was an obvious design flaw that clearly affected efficiency and circulation.

However, I tried to look past this and see what opportunities still provide learning experiences.

Entrances to BWH along Binney St.

Going to the Hospital

7:45 am

Going to Brigham and Women’s (BWH) was unique for because I lived less than half a mile from the hospital this summer. It will probably be one of the few times in my life that I’ll be able to simply walk out the front door and walk to the entrance of a hospital.

However, it gave me the ability to fully experience a hospital in an urban environment at the street level, and as a pedestrian. As I mentioned, I had been to the hospital before for projects, so I tried to experience it from the viewpoint of someone going for the first time.

There were two major elements that caught my attention on the way to the entrance. First, there were no signs that pointed pedestrians to the entrance, just large wayfinding sings intended for cars. These signs simply listed entrances as street address and the Emergency Department. The second element is that there are many entrances a pedestrian will pass that compete for attention and make the main entrance unclear. Coming from the Brigham Circle T-stop, you first pass the promenade of the original building and then farther down the entrance to the ambulatory part of the hospital.

This entrance has a vehicle drop-off, but is still fairly pedestrian friendly. Once you finally get to the main entrance, your attention is instead drawn to the large cardiovascular center recently completed and designed by NBBJ. The building is sleek and modern and has a large “Brigham and Women’s Hospital” sign on the side. This large building distracts from the actual entrance which has a low covering and is pulled back from the road. Going from the old building down to the main entrance, the entry points to the main hospital are less and less inviting and pedestrian friendly.

The pictures above illustrate the various entrances and how the one with the most grandeur and appeal is actually the one farthest from the main entrance to the hospital.

Wayfinding sign off of elevator on lower level 2

Getting to the Department

Sign to Rad. Onc. above corridor from elevator

7:55 am

Once I entered the hospital I realized that I had always followed someone on the project team to the radiation oncology department and had no clue where I was going. There’s a reception desk right as you enter the hospital, and then the elevators are off to the right. There is a sign that could help visitors find there way, but it pretty much fails since it is just a long list of text of all the departments.

Once I figured out where I was going I took the elevator down to Lower Level 2. As you get off the elevator your faced with another sign that is just all text, but has little arrows pointing you in the right direction. The corridor is pretty lifeless and just a long hall of doors. However, the department is situated fairly well in that it sits at the very end of the hall. As you start walking towards it you’ll finally see a sign hanging from the ceiling that points straight ahead to “Radiation Oncology”. So even though the signage isn’t great, the location and warm textures / colors of the waiting room help to draw in patients.

Main Waiting Room

8:00 am

The waiting room was a strong contrast to the stark white corridor that you walked down to get to it.

The room is done with lots of light colored wood paneling, giving it a warm and welcoming feeling without seeming dated. Several paintings on the wall also help to make the waiting area inviting. The dept. offered free snacks, reading materials, and a TV to keep patients occupied. I later would find out that the water station at the snack area was important because some patients were required to have a full bladder right before treatment to help with imaging.

However, the snacks were just out on a table and started to get messy, It would have been nice if there had been some foresight to provide some casework to organize and store the snacks.

The set-up of the waiting area worked well to separate it from the flow of patients and staff in and out of the department. This is done with just two columns that define the waiting area. While I was waiting it was nice to see nurses come out and lead patients back, and it made me wonder what implications that would have on far they were having to walk throughout the day.

To Vault

Nurse’s Station

TLT Soiled

2.

1.

Gowned Wait.

Change 3.

Gowned Wait.

Change

4.

Change

TLT TLT Waiting Area 2.

2.

Waiting Heavy Circulation

To Change + Sub-wait 1.

Reception

Main Department waiting area

I thought it worth mentioning how patients come into the waiting area and check-in. Return patients who are already in the system are given a card with a barcode that the scan when they arrive to checkin. The scanner is at the front desk where staff is sitting, so it’s not like just going up to a kiosk and not having any human interaction. Then patients will wait until they are called back. Before they are given their radiation treatment, they will scan their card in the vault to ensure they are the right patient and receiving the right treatment.

Todd Vivenzio, the head of radiation therapy at BWH, emphasized that it’s a way for them to ensure the safety of the patient, but he worries about giving off the impression that patients were being reduced to a barcode and losing the human touch. Todd also mention their scheduling and database system, Aria, that keeps all treatment, planning, and followups in one system. Their intent with this system is to prevent any errors that may arise from manual entry of information from database to database as patients move through the radiation therapy process.

After that quick overview, Todd led me out of the waiting room, and away from the main department, to the TX Suite down the corridor. The

TX Suite Waiting area

waiting area for the TX Suite is a little strange because there is a small waiting area right when you walk in, but the scanner for the patient cards is farther down by the gowned waiting. Therefore, most patients will scan their cards and then just wait in the gowned waiting regardless if they’ve changed or not. The waiting areas are divided here, presumably for men and women, but that doesn’t seem to matter. The nursing station here has a clear view of the gowned waiting, but can’t see down to the initial waiting area.

The changing rooms are directly off the gowned waiting, and I will compare these to the main department changing rooms later on.

ELECT CWL220E

Storage

Exam

Soiled

Exam

Cln.

LINAC Vault

LINAC Control

TLT Nurse Station

Waiting Area

Gowned Gowned Wait.

Wait.

Clinical Treatment Clinical Support

Change Change

Admin.

Suite

Clinical Service Patient Areas Patient Support Plan of the TX Suite within the Rad. Onc. department

ADMINISTRATIVE SUITE CWL219

STAFF LOUNGE CWL216

TOILET CWL215

MATERNITY STORAGE CWL217

CONFERENCE ROOM CWL216A

Right away one of the first patients was brought in for treatment. She was an inpatient, so she was brought in on an stretcher that was then placed right next to the treatment “couch”. The therapists asked if she would like to get on the couch herself or be slid over by them. She asked to be slid so one of the therapist grabbed a slide board from a closet to help move her.

Before they moved her onto the couch they verified that she was the right patient and one of the therapist who hadn’t treated her before introduced themselves to her. They placed cushions under her head and knees to make her more comfortable and also help

SPRINKLER STANDPIPE CWL210

RADIATION TREATMENT #1

ELECT

HOUSEKEEPING CWL209

Todd next took me too the control room for the LINAC that the TX Suite was built for. Here I was handed off to the radiation team running the machine. But first, Todd had to point out an alcove that was meant to be for a crash cart, except the metal bumper around the cart was not taken into account. So the crash cart does not fit into the alcove, and now has to be stored a little further from the treatment vault.

to position her. One of the therapists pointed out to me that they can play music for the patients and that there is also a step ladder they keep in the room to help patients get up on the couch.

After the patient was positioned, I went out into the control room with the therapists. As they finished preparing everything for the treatment, Keven pointed out that they really didn’t like all the cables below the control counter. He even mentioned that some of the pieces of equipment are turned in odd ways in order to make sure someone didn’t accidentally hit the power button with their foot while sitting at the counter. It seems like some sort of furred out casework with access panels would help to hide the cables and equipment while still allowing for easy access. There is also an intercom to allow the therapist to talk to the patient. They have standing height counters and tall task chairs to work.

I assumed this configuration makes it easier on them when going back and forth between the control desk and the treatment vault.

One thing that was most noticeable about the control room was how big it is. It definitely cannot be an efficient use of space, and even though they have a lot of storage, many of the over-counter cabinets HOUSEKEEPING CWL217A

8:15 am

ELECT

TX Suite | LINAC

TX Suite Linac Vault

are way out of reach for some therapists.

After the patient’s treatment was completed, the patient was slid back onto the stretcher and taken out of the room to the inpatient holding area by Kevin. There was a decent amount of storage in the vault by Corina mentioned that she wised the storage was better suited to what was being stored. Some of the cushions they use are strange sizes and shapes making it difficult to organize them in the cabinets. I began to think about how you could not only provide ample amounts of storage, but also storage that was suited to what would be stored there.

RADIATION TREATMENT #2 Sliding the first patient off and on the stretcher took a decent amount of time and also required more of the therapists in the vault to assist. The next patient was a strong contrast because it was an outpatient who simply walked in and got up on the treatment couch. This difference really showed how not only do inpatients take longer to treat, but also they create inconsistencies in the work flow of the therapists. This second patient was in and out with very little hassle. The quickness of his treatment

caused me to ask Sarah, the chief radiation therapist, about the number of patients they treat every day.

She estimated that between about 6:00 am to 8:00 pm they would treat anywhere to 35 to 55 patients depending on the day. One interesting way they are able to inform patients about delays in treatment is through monitors in the waiting area that display the expected delay time for each radiation machine.

I observed four more radiation treatments after these first two, but the flow mirrored what was observed in the previous ones. There was nothing new to note, and I began to realize the repetitive and borderline monotony of the therapy staff. I asked the head therapist what she thought about this, and she said she is never bored because each case is slightly different and brings new challenges.

View of control room from Linac vault entrance

Cables and control boxes below control room desk

TX Suite | Layout

View of control room facing opposite direction from image above

10:00 am

As I mentioned at the beginning, the radiation oncology department is fragmented. The TX Suite is down the hall from the main department, and poses quite a challenge for new patients trying to find it. The first obstacle for staff is the distance that therapists have to walk to get or take an inpatient to and from the inpatient holding area. The holding / recovery is approximately 50 steps from the entrance to the TX Suite, which is roughly 102 feet.

One thing that I didn’t like about the waiting area and nurses station was how the doctors would discuss patients at the workstation at the end of the nurse station. Anyone who really wanted to hear could listen closely and most likely overhear any conversation about patients. The computer at this area also faces the OTV rooms, so anyone leaving them could see information / images on the screen.

I think they would benefit by having some sort of alcove or separated work area to make things more private.

I then asked Kevin what were some of the things that slowed down the staff and treatment times during the day. Him and Corina listed the three

major areas of slow down as: 1. Getting inpatients from the holding / recovery area 2. The separated department that can potentially cause patients to go to the wrong area 3. Trying to align patients on the machine and having to try multiple times to get everything to line up. The first two issues are a direct cause of the separation of the department and shows how layout really affects efficiency.

After he told me all this, Kevin thought it would be a good idea for me to go down and see the inpatient holding / recovery area. The recovery area reminded me of a pre / post-op space. There were bays for patients separated by curtains. I know if I were an inpatient and having to stay down here for a little bit I would be pretty uncomfortable. It makes it seem like you’re in a horrible condition. Patients also have very little acoustic privacy if the doctor comes over to talk about their treatment. It would be nice to see more separated and isolated areas for this. I’m not sure if there’s a more efficient way to move patient rooms in order to hold fewer patients in the area and devote more space to private bays.

Travel Distance: 237’ 5”

LINAC Control

TX Suite

Recovery

Distance from TX control room to inpatient recovery / holding

Changing Rooms

10:30 am

While we were over in the main department, Kevin made a point of noting the differences in the changing rooms for the two separate parts of the department. He thinks the ones in the TX Suite are much better and just make more sense overall. The major differences are noted in the diagrams above, but some of the differences aren’t as noticeable in plan.

The changing rooms in the TX Suite are actual, full rooms with a door. There were also lockers within the room so patients could temporarily store their clothes in their during treatment. They were fairly spacious too. On the other hand, the changing rooms in the main department aren’t fully enclosed rooms. They were more like stalls you would go in to change, and then lockers were located outside, around the corner from them. Patients are more out in the open here and don’t have as much privacy.

However, it is worth noting that patients in the TX Suite go back to the main waiting after changing, where as the main department as a sub-waiting for patients that have changed into a gown.

Patient Precautions

10:55 am

While we were over in the main department, Kevin made a point of noting the differences in the changing rooms for the two separate parts of the department. He thinks the ones in the TX Suite are much better and just make more sense overall. The major differences are noted in the diagrams above, but some of the differences aren’t as noticeable in plan.

The changing rooms in the TX Suite are actual, full rooms with a door. There were also lockers within the room so patients could temporarily store their clothes in their during treatment. They were fairly spacious too. On the other hand, the changing rooms in the main department aren’t fully enclosed rooms. They were more like stalls you would go in to change, and then lockers were located outside, around the corner from them. Patients are more out in the open here and don’t have as much privacy.

However, it is worth noting that patients in the TX Suite go back to the main waiting after changing, where as the main department as a sub-waiting for patients that have changed into a gown.

Gown Storage Lockers

Nurse’s Station

Sub Wait.

Vitals Station

Nurse’s Station

Waiting Area

Waiting Area Gown Storage

Change 28 ft2

Change 28 ft2

Change 62 ft2

Change 62 ft2

Lockers Gown Storage

Lockers outside room

Plan of Main Department changing area

Plan of TX Suite changing area

Patient OTV Observation

1:00 pm

I next got to see the other main activity of the department which is follow ups and consultations with patients in the OTV (On Treatment Visit) rooms.

After watching several radiation treatments, they became a little monotonous and some doctorpatient interaction was a nice change. I shadowed nurse practitioner Rich Boyajian as he had a follow up with a patient who recently completed treatments. I was very pleased with the layout of the room. This impression began right when we walked in the room and the patient was seated in a guest chair by charting area, as opposed to sitting on the exam recliner in the corner of the room. Rich sat down at the work counter right next to the patient’s chair.

With this arrangement, Rich was able to look back and forth easily between the patient and computer on the counter, as well as maintain the same eye level.

The patient was extremely friendly and the conversation between them was very laid back. I believe the laid back feeling of the conversation would have occurred with any patient because of the setting and not just the personality of this particular

patient. Rich would have had to be looking back and forth between the patient and computer if the patient had been sitting on the recliner. The patient even mentioned that he usually comes in anxious but leaves much more relaxed and reassured. I think the informal and welcoming layout of the room helps with this, as the patient and doctor are able to have a discussion, and it’s not just the doctor dictating to the patient.

At the end of the appointment, Rich brought up a new service the department is thinking about implementing. The service is a sort of online clinic that would allow doctors to monitors a patients health through simple input that would not require the patient to come all the way to the hospital. Rich asked the patient if he would be interested in this service, and right away the patient was very hesitant.

They were worried that the service would create a detachment between them and his healthcare. They believed it would devalue them as a patient and give off the impression that no one cares since there is no human interaction.

Dr. Rich

Recliner

Patient

OTV Room #1

OTV room where I shadowed NP Rich

Clean

OTV Room #2

TLT Soiled

Plan of OTV rooms in the TX Suite

Shadowing Medical Assistant

2:00 pm

For the remainder of the day I would either go back into the control room to watch more treatments, or shadow the medical assistant working the nurses station in the TX Suite. The medical assistant (MA) was a girl named Katie who was about my age. Her title really explains it all, but her main responsibility is tending to patients and making sure they get checked-in. She has to make many trips up to the main waiting and back to get patients for follow ups and consults. However, she prefers to use the vitals alcove up in the main department because it gives patients a little more privacy. The vitals “station” in the TX Suite is a chair next to the nurses station with a rolling pole that has the blood pressure cuff and thermometer.

One thing that seemed pretty odd to me was that occasionally Katie would go down to the main waiting area and there wouldn’t be anyone watching the TX Suite. There are staff close by if someone did need help or if there was an emergency, but I was just surprised how the physical separation could pose a problem in an emergency.

View of other OTV room in the TX Suite

Overall Evaluation I had a hard time getting a good sense of the overall department having mainly shadowed the TX Suite today, but I thought the overall workflow in the suite worked quite well. The only things that seemed strange were related to the physical space.

Even though the set up of the department isn’t an ideal condition, it gave me a great example of the consequences of having to just put program where it will fit during a renovation.

A combination of the two changing room area is preferable; full rooms with lockers included adjacent to sub-waiting area. There is an optimal size for control rooms, otherwise they begin to lose their efficiency. I think there should be some sort of work or charting alcove so patient information isn’t as visible. I appreciated that Todd showed me how an alcove designed for a particular piece of equipment was done in correctly and taught me to really understand the equipment I am designing for. Lastly I really liked the layout of the OTV room I shadowed and the interaction it enabled between patient and care provider.

DATA DATA

CT Sim

Treatment Planning

Control

CT Sim / Brachytherapy Vault

Offices

Control

Offices

Reception

CT Sim

Waiting Area

Patient Prep / Recovery

OTV Rooms

Control

Control OTV Rooms

HDR-TBI Vault

Control

Brachytherapy Vault

Radiation Treatment

Control

2.2 | OBSERVATION 2

Brigham + Women’s Hospital Radiation Oncology Department June 8, 2016 8 hours

Brachy.

Planning

Control

LINAC Vault

Control

LINAC Vault

Diagnostic / Imaging

TBI Vault

Exam Rooms Staff Core / Support

Intro A week after shadowing in the TX Suite I had the opportunity to observe in the BWH Radiation Oncology department again. This time I was going to be observing in the main department and learning about some of the services that aren’t just radiation treatment. I was excited to see how the main portion of the department functioned in comparison to the TX Suite, and also see the interaction between the two areas.

I started the day shadowing in the CT simulation room, and then transitioned to following a nurse practitioner who is part of a palliative care organization in Rad. Onc. I finished the remainder of the day in the core / nurses station of the department observing and taking note of key interactions.

Storage

Electrical Room

CT / Brachytherapy Procedure Room Privacy Curtain

Storage

Sc

ru

b

Si

Storage (Initially Patient Waiting)

Control Room

nk

Physician Work

Storage

Waiting

7:50 am

I started my morning similar to how I started my first observation by waiting in the main waiting room for Todd. The biggest difference this morning though was that the waiting room was packed! I couldn’t understand what was going on because it was the same time and same day of the week as last week.

There were only a handful of people in the waiting area during my first observation, but today there were only two seats open when I arrived.

I laster asked one of the NP’s what the difference was and she said she had no clue. She checked the schedule and there didn’t appear to be anymore appointments than normally. The waiting room was much louder because of all the people however. The space was also cramped and I found it to be a little overwhelming. A man walked through the waiting area at one point with a hospital gown on to the go to the bathroom. I wasn’t sure why he had to use the restroom in the waiting, but I don’t know how I would have felt going past all those people with just a hospital gown on.

CT Simulator

8:00 am

I went to one of the CT Simulators after the waiting room. The entrance to the room was a sliding door directly off a corridor that is not within the department. Because of this, there are curtains inside the sliding door to block any views to the patient during simulations or procedures (the room is also used for HDR procedures). There is a small scrub sink just inside the door that has boxes of masks and extra soap bottles just resting on the back of the sink. The control room was fairly small with just a standing height counter. There was also a small work area for the doctors directly behind the control area.

Under the counter is a large GE control box for the CT, and the top of that box has been turned into an improvised storage shelf.

I think the control area would benefit from a lot of tack boards, or similar material, to reduce the amount of papers just taped directly to the wall. It causes the room to feel messy. There was a x-ray view box, about 3’ x 5’, in the work area that is obviously not used for reading film any more so it has been turned into a makeshift bulletin board.

View of CT scanner and work counter from door to procedure room

Patient Scan

8:30 am

I went into the CT room while the team was waiting on the first patient to arrive. Since the room is also used for HDR procedures, there are a few booms on the ceiling with surgical lights and monitors. It is a fairly large room with a Sky Factory-like fixture installed above the bed of the CT. The techs also had music playing in the room while they were setting up, but then turned it down slightly when the patient came in. They didn’t ask what the patient would prefer to listen to, just chose for them during the scan. I thought it was odd that there was a mix of polylaminate and stainless steel casework in the room. I wasn’t sure why they wouldn’t all just be done in one way. I originally thought the stainless steel storage would be used for storing HDR supplies, but then a med student retrieved supplies from it for the scan.

The patient that came in for the first scan was actually the man who walked through the waiting area with just the gown on. The med student asked him to lay face down on the table. The patient was asked how much water he had consumed, if he was comfortable, etc. I’m unsure as to the purpose, but

the oncologist came into the room and prepared what looked like a catheter at the counter that was then inserted into the patient’s rectum. The prep area where the oncologist prepared this was just a paper towel on the counter that had a couple computers and the speaker with the iPod. The staff then stepped out of the room and commenced the scan. Afterwards the med student took pictures of the patient on the bed as reference for lining up patients for treatments, in case there is any uncertainty.

During the review of the scan in the control room, the doctors kept getting up from the workstations to come over to check and double check the scan. This happened several times, and made it a little cramped in the area, but I would not say it needed to be a bigger space. Lastly, the techs put small tattoos as alignment spots on the patient for future treatments. Then the patient got up from the table, covered up with the gowns, and left the procedure room. The med student then cleaned the room up and prepared for the next patient.

Meanwhile the techs worked in the control room to save the previous patient’s information and pull up the right information for the next patient.

There were a couple additional observations

Work counter in CT Sim room [ paper towel is where catheter was prepped ]

GE control box used as a shelf in control room

I made about the room during and after this scan.

The back splash behind the counter in the procedure room had a row of med. gas outlets that seemed very impractical. If hoses were connected, they would be going around computers, stuff on the counter, etc.

One of the techs, Katherine, said that they never use those gas outlets and just use the ones on the opposite wall. On the opposite wall was also located a WOW (workstation on wheels). One tech may occasionally go over to the WOW during set up, while another would prep things at the counter. It did not appear that the computer had any connection to the wall other than power, so I began to wonder if the WOW could be located by the counter instead. I thought this would make the points of interaction closer together for the techs as they prepare the room. The final thing I found peculiar was the ceiling condition.

Over the machine, the ceiling in the room changed from acoustic ceiling tiles to gypsum. However, it was not a soffit, but just a straight transition at the same elevation. It was not a clean transition and just provided a rather strange look to the room.

View of control room workstations

SPRO

11:00 am

After shadowing in the CT Simulator, Todd introduced me to Andrea Kelly and the SPRO (Supportive and Palliative Radiation Oncology Services) team of the Rad. Onc. department. I met Andrea by going into a small room, maybe 8’ by 8’, where six people were already meeting. This was the SPRO workroom and it left much to be desired. There was a workstation in the corner that Andrea mainly worked at during the day in order to be closer to the department. Her office, and the other SPRO NP’s, was down around the corner and was just too far to travel during the day. They also had to have a code lock on the door to their offices since it was off a main corridor. The workroom has a small, round table, maybe 3’ in diameter, 3 stools and 4 chairs. As small as it was, I was surprised how little is stored in there other than what was put on tack boards or whiteboard on the wall. There was an old x-ray view box on the wall, maybe 3’ by 4’, that obviously is no longer used for reading films and has instead become a make-shift bulletin board.

Changing area in Main Department

Visiting Inpatient Room

View of OTV rooms in Main Department from nurse’s station

12:00 pm

I had the opportunity to go up and visit a patient in the bed tower while I was shadowing Andrea. The patient was recently diagnosed with cancer next to her spine, and the tumor was causing a great deal of pain pushing against the spine. I have to say I was actually quite shocked by the patient floor. The unit itself was very chaotic and crowded, I wondered if it was some specialty unit because it was so unlike what I am used to. When we went into the room, I was further shocked to find that it was a shared room. The patient we were visiting was closest to the door and there was just a curtain separating the two patients.

The patient we visited had three family members in the room: a son sitting by the door, a brother standing behind the door, and a daughter sitting on the foot of the bed. There was already a doctor and nurse in the room when we entered. There were now seven people surrounding the bed with our addition in what was essentially half a patient room. While the doctor and Andrea talked to the patient, we could hear the neighboring patient talking to The Price is Right on the television.

The doctor and nurse left leaving just Andrea

to talk to the family about treatment options and the need to do radiation to reduce pain caused by the tumor. Andrea decided to stand on the opposite side of the bed since the family was by the door.

This meant she was sandwiched between the two beds, with just a curtain behind her to separate her from the other patient. Andrea went through the treatment options, comforted the family and patient, but the whole time it was jarring knowing that a strange patient on the other side of the curtain could hear all of this information. In addition to us being able to hear her ranting at the TV. After talking to the patient, we headed downstairs and I asked Andrea about the inpatient floor and if most rooms are shared like this one. She said that they were, except for ICUs and some other exceptions. I later followed up with Todd about this and he said that state law now prohibits shared rooms, but several hospitals in the city, including BWH, have nowhere to put patients currently in shared rooms. Therefore, these hospitals are grandfathered in and allowed to have shared rooms, but the hospitals must be in the process of constructing new bed towers to eliminate the need for shared rooms.

TLT OTV OTV Room #6 Room #5

OTV Room #4

Soiled

Total Distance: 232’ 3” OTV Room #1

Nurse’s Station

Inpatient Recovery

From Room

Waiting Area

To Room

TLT

OTV Room #2

Brachytherapy Control

Brachytherapy Vault

OTV Room #3

Path of travel for taking Chinese patient to OTV room and then back to inpatient recovery

Back in Rad. Onc. Department

12:30 pm

Andrea and I spent some time in the workroom before heading over to the inpatient holding area to talk with a patient. Andrea mentioned that she wished the inpatient holding area had a little more privacy since now it just has curtains dividing the patient bays. Andrea was going to be talking to a Chinese patient, and the interpreter was out of town so she would have to use an interpreter over the phone. A nurse took the patient into one of the OTV (On Treatment Visit) rooms so he could better hear the interpreter and we could have some privacy.

We had to use the only OTV room that is designated for handicap patients since it is the only room that can accommodate a full stretcher. I’m not sure what happens if a handicap patient comes in and has to wait just because there was not enough privacy in the patient recovery area.

In turns out the patient spoke a unique dialect of Chinese that the interpreter could not understand and there was no one else at the interpreter center that could help. Andrea was embarrassed to have to call the patient’s daughter and see if she could come in later in the day to assist with translations for

approval of treatments for the patient. After bringing the patient down and taking them into the OTV room, the patient had to be taken all the way back up to his room in the bed tower without any treatments or approvals completed.

While we were talking to the Chinese patient, the woman from the bed tower and her family came down to have a CT scan done. I enjoyed being able to see the whole process of visiting the family in the patient room, seeing them come down to inpatient holding, have the CT, and then go back to holding before being taken back up. While this particular patient was getting set up to have the CT in the same manner and order as the previous CT patients I observed, there were a good number of people in the control room. There were seven people in the room, and this just showed me how the number of the people in the room could vary so much during the course of the day depending on doctors and other staff that wish to be present during a patient’s diagnosis.

From Elev.

Lobby

Waiting Area

TLT

Pediatric Playroom OTV Room #6

OTV Room #4

OTV Room #5

OTV Room #1

Change

Vitals

Change

Soiled

Nurse’s Station

Sub Waiting

Views to Rooms

To Treatment Vault

Brachytherapy Control

OTV Room #2

OTV Room #3

Brachytherapy Radiation Vault Treatment Patient Consult Visit Patient

Visibility and circulation around nurse’s station

Main Department Core

2:00 pm

After watching that patient’s CT sim, I decided to go over to the main radiation oncology department and stay in the center to watch the ebb and flow of both staff and patients. At the center of the dept., just off the waiting area, is a nurse’s station that is the hub of the dept. The station had a split counter that is standing height along the corridor and sitting height within the station. There were two medical assistants (MA) who sat at the station most of the time preparing appointments, bringing in patients from waiting, and taking vitals. Doctors and nurses would flow from OTV to OTV and then stop at the standing height counter to do some charting or just chat while waiting on their next patient. There was a lot of communication at this hub for the staff and if any of the MA’s were looking for a particular doctor to tell him something, they would most likely walk by in a couple minutes. A couple WOWs were along the corridor, right next to the nurse’s station, which doctors would use. I do wonder if it would be better to create a small work area just off the back of the nurse’s station or something similar so that doctors could share information about patients without

the risk of patients overhearing while going to OTV rooms.

The nurse’s station was pretty organized, but they had a precarious stack of several iPads in protective cases they give to patients to do a quick assessment. The assessment of pain, tiredness, and other conditions is added to the patient’s record as a way of tracking the progression of a patient. Patients doing this while they wait helps to cut out time spent by nurses transcribing what the patient tells them in the room. It would be good for them to have some sort of organizer or storage space for the iPads so they are not piled up on the counter. This is an example of new technology influencing design and requiring specific storage space.

As the MA’s would bring in patients, they would take them to a little alcove right next to the desk to take vitals. There was plenty of room here and it gave the patients some privacy from the hallway (Katie on my last observation noted how she would typically do vitals there since it was more private and then take them to the TX Suite). One patient came to have vitals taken who was in a lot of pain. There was plenty of room for the MA to bring a wheelchair into the alcove and then take her straight to the room.

Vitals alcove adjacent to nurse’s station

All the doors for the OTV rooms had small whiteboards on them with the doctor’s name, and what the doctor would be doing. All but one of the rooms was visible from the nurse’s station, so it seemed like an effective way of keeping track of where doctors were and where they would be going next. One of the MAs explained that they had to put only the doctor’s name because it was a violation of HIPPA requirements to put any patient information on the white board. She told me this as I was following her to the linen supply area over by inpatient recovery. She comes over to this area in order to restock the linen cart that is stored between the two changing rooms in the main department.

There was a small arrangement of flowers on the counter of the nurse’s station that was a big hit for the patients, and I found their reaction to be amusing. One woman raved about how pretty she thought the flowers were and another man stopped to smell them on the way out. This was one of the first times I have seen people enjoying aspects of nature in a space, without them being asked about their opinions. The reactions caused me to think about how nature elements could become more of single focal points, similar to this one flower arrangement,

and not used at every chance; working to find a balance between too much and too little.

Overall, I felt that the nurse’s station is positioned very well in the department. The station was right next to the entrance from waiting so the Mas could direct patients coming and going. This also did not require them to walk very far to lead patients in from the waiting room. The MAs also have good visibility of the OTV rooms except for one. The department also seems much more geared towards outpatients in terms of flow. The movement of inpatients in and out of the department seemed to be the biggest source of problems both spatially and operationally. I began to wonder how the department could be set up to better handle when staff have to get patients as opposed to when the patients come to them.

View of nurse’s station from door to waiting area

TBI Vault Control

4:00 pm

After hanging out at the nurse’s station for a while, I decided to pop in to the control room for the TBI vault since I had worked on one last summer. Their TBI machine is fascinating because it was custom made for the department in the 70’s. The vault has a radiation machine buried in the floor and one above the patient in order to radiate the entire body evenly as the patient lies between the two machines. The control room has to have curtains in the hallway that can be drawn to block any views to the monitors of the patients being treated. The techs said while the curtains serve the purpose, it is not great because someone will inadvertently leave the curtain open, or if someone pokes there head around it someone could easily see through the opening. The techs pointed out the 2-way camera and microphone that they have in the control room not only to talk to the patient, but also so younger patients that have to be treated for long amounts of time could have their parent read to them.

Overall Evaluation This observation of the radiation oncology department gave me a better understanding of the flows and connections to other departments than my first observation. I really enjoyed being able to observe the journey of the patient from the patient room, to the department, into treatment, and back to their room. However, her case and the case of the Chinese patient showed me the value of having a more private recovery area, or just providing a single accessible consult room in the area. I also learned that in a department that treats both inpatients and outpatients, how staff have to transport inpatients can have a large impact on efficiency.

I did find it strange how certain procedure rooms, like the CT Sim room, were directly off of a main corridor as opposed to being within the department.

I could see how it would make navigation a little more confusing for patients, but it also requires the room to have curtains for privacy. The OTV rooms suffered from a lack of flexibility since only one of the rooms is handicap accessible. This set up requires staff to put additional handicap patients in smaller rooms that make them cramped. Lastly, I thought

Patient subwaiting within Main Department

the placement of the nurse’s station worked really well. I liked how it was at a major intersection within the department, had visibility to all but one OTV room, and was adjacent to the waiting room to assist patients.

I really enjoyed my time in the radiation oncology department. I learned so much about not only ideal layouts and adjacencies, but also the role of staff culture and their close interactions with patients they see weekly. I have a lot of respect for the staff that work in a very high stress and occasionally emotional department.

Pediatric playroom within Main Department

Boston Children’s Hospital Entrance | Source: http://www.newkidscenter.com/Best-Children’s-Hospitals.html

2.3 | OBSERVATION 3

Boston Children’s Hospital Hospital Technology Walkthrough June 14, 2016 8 hours

Intro Boston Children’s hospital is in the process of completing two large building projects. They will be adding a new clinical building to the main campus, and a large addition to their Waltham campus.

The hospital is planning for the new buildings to have the most current technology, and to achieve this goal they hired IT consultants from RTKL. I had the opportunity to shadow these consultants and hospital staff as they went through multiple departments of the hospital and discussed potential changes in technology.

This observation opportunity was very different from my other ones because I was moving around the hospital so much, but I have to say this observation was one of the most informative. At first, I was unsure how much I would be able to take away from the shadowing, but I soon realized what a large part technology plays in the hospital. We have discussed in class the impact of technology on providing care, but this observation showed me so much about the impact technology has on space planning and efficiency.

Operating boom filled with equipment and cables

Surgery Suite

8:00 am

We started on the surgical floor, where I will admit beforehand that I didn’t take much away from this part. Stephanie first talked about the typical flow they have for the surgical floor and then took us into the clean core to show a little about their storage and how they connect to the ORs. The focus of the technology component was at the nurse’s station at the front of the department. The all-organizing element here, that I did not realize existed, was a series of monitors that list every ongoing or recent operation and its current status. Therefore nurses, doctors, etc., could track the progress of a surgery in order to prepare for pre and post op transfers and also be aware of the location of surgeons at all times. They also has physiological monitors that would show the conditions of each patient that was undergoing surgery.

The one thing that struck me about this area though was the amount of papers and bulletin boards on the wall. Stephanie and some other surgical staff commented that they would prefer to see less in the future. The nurse’s station also had workstations for the charge nurse and charge anesthesiologist.

Corridor of surgery suite with signs on ceiling indicating equipment locations

This nurse’s station really was the control center of the entire surgical suite. There were some security monitors mounted on the wall which they said were rarely used, but wouldn’t be removed. Already I was beginning to see just the amount of screens and wiring that was needed to ensure this control center functioned properly.

As we stood in one of the hallways talking I noticed the amount of equipment (crash carts, C-arms, etc.) stored in alcoves. There were signs along the ceiling at each alcove or room indicating what was there, so if you were to walk out of an OR looking for a crash cart tucked away in an alcove you could easily find it.

Inpatient Unit

9:00 am

We next went up to an inpatient floor to see what technology was currently being used and how it could be improved. One of the first things that Stephanie pointed out was that practically everything was cart driven (WOWs). While there are some central charting areas, most nurses are doing their work at these carts either in the patient room or in the hallway.

Headwall and workstations in an inpatient room

Wire basket attached to headwall to hold Playstation controller

Stephanie also mentioned that the patients’ rooms in their new building would have a med. gas boom in each one; ICU rooms will have two.

We then walked into a room that could hold two patients. There were TVs for each patient bay that connected to a Playstation with the controller for the console coming out of the wall. A wire basket was screwed to the wall to hold the controller and keep it from falling to the floor. Stephanie and the consultants talked about a program called Get Well that is meant to be a patient education system on the TV. She made it clear that patient education would be tied to the entertainment system and would make a TV in the room essential. There was a WOW in the room and Stephanie mentioned that a lot of time a WOW will just stay in each room and will not be taken out. She feels like if something is going to go in a room and not leave then it should just be hardwired in so it can take up less floor space and not use up the unit’s Wi-Fi. Next, we went down to a charting station at the end of the hall. There was a main station at the center of the unit, and then two smaller ones at each end. Each station though had large monitors that displayed the status of each patient. This makes it

easier for a nurse to monitor their patients, but also for the entire staff to keep an eye on any patients with issues. These monitors were essentially just large screen TV’s, and would definitely have to be taken into consideration in the design. We next went back towards the central charting station and into a small room that was the charge nurse station. In this room was a monitor mounted on the wall. Unlike the monitors at the charting stations, this one was touch screen and would allow the nurse to see the status of all patients and track patients as they moved through the hospital. This way they could have a better idea of when a patient would be coming out of surgery and they could prepare.

Adjacent to the charge nurse’s station was a workroom for residences and fellows. This room had a number of workstations and WOWs that any resident student could use. There was also a large monitor on the wall for them to look at echocardiograms or other images and discuss with fellow residents or doctors. It was a small space that needed to include both individual and collaborative type work. Designers would have to make sure there are plenty of connections and workspace for all the needed computers in the room.

Headwall in inpatient room with dedicated WOW

We went into another nursing unit that was part of a recent edition that Payette designed. The main difference with these patient rooms is that they used med. gas booms as opposed to wall outlets like in the other rooms. The boom was absolutely covered in wires and equipment. Unlike the WOWs stored in the room before, the booms had mounted workstations on them. I later asked Susan in the office about the benefit of the booms in lower acuity rooms, and she talked about how they allow the bed to adjust slightly while the patient is connected to equipment.

There was also a playroom on the floor, which is not something I would have thought of right away.

Stephanie mentioned that they have really enjoyed using programs like Microsoft Kinect and Nintendo Wii because it causes patients to get up and move.

The game console acts like a form of physical therapy, and since it is all motion based, there is no infection risk of patients touching toys and potentially passing on germs to the next patient who uses them. It made me think about how the layout and sizing room might change to be more geared towards a motionbased gaming system.

Corridor of the inpatient unit

Cardiac ICU

11:00 am

After the inpatient floor, we went to the Cardiac ICU for a quick tour. I had never been in a unit of this type before in terms of the intensity and overall stress level.

Seeing kids, especially small newborns, hooked up to all sorts of machines was hard to see. Since we were focusing on technology today, I was really moved by seeing a husband and wife sitting next to their baby.

Both mother and father were holding the hand of the newborn while staring intently at the physio monitor to watch the condition of the child. They were reliant on technology to let them know how their child was doing.

One piece of monitoring equipment that Stephanie told us about was a new system called persistent display. The program tracks the vitals and conditions of the patient in order to predict how they will be in the near future and better prepare staff for any potential emergencies. Since this unit has staff in the patient spaces more and moving around, they utilize a decentralized system of Pyxis machines to get medications to patients faster. There is also a dedicated WOW “parking area� so they do not float around in the halls and can charge. I thought the

Workroom in the inpatient unit with workstations for residents and fellows

parking area had an interesting design implication, because I do not think it is necessary, and might not even be included in the program, but could be extremely helpful in organizing and tidying up the corridors of a very intensive unit.

We did not spend a ton of time in this unit in order to not distract, but it was obvious how big of a role technology plays in these type of units. Patients are constantly monitored and most of the equipment in the rooms is critical to their well-being.

Radiology

1:00 pm

We next went to the radiology department to learn about patient and staff flows. The main thing I learned about in this department, and was surprised to learn, was that Boston Children’s uses a lot of custom made computer software to schedule and track their patients. These programs developed out of a necessity to reduce errors in patient transfers from inpatient to diagnostic departments. This not only allows the radiology staff time to prepare, but also there is no switching between programs to track the patient and risk causing medical errors.

While this new found knowledge has little design implications, it was fascinating to learn how the hospital operates and that they really have to be innovative and just figure out what works best for them in terms of keeping track of their patients and reducing any errors.

After these talks about keep tracking of the patient, the conversation shifted to how they keep track of staff. Stephanie talked about how the big thing now is for staff to all have mobile phones with them as opposed to beepers. The only problem with these phones is that people will be calling each other all the time and staff are tempted to answer them while in the room with patients. The other problem is staff coming into rooms to tell other staff members something because they know they are in the room and do not want to risk not being able to find them later. They mentioned they would like to have a way of leaving each other messages and notes so that the doctors and nurses are not distracted as they are interacting with the patient and can focus on caring for the patient.

Audio / Visual

3:00 pm

We next met with the director of A/V for the hospital, and the biggest thing I took away from this is the push towards telemedicine and the effects it is starting to have on the built environment. They talked a lot about having the proper A/V equipment and setting to be able to diagnose properly over telemedicine.

They also talked about how the software they use to conduct telemedicine has changed to a more webbased system, which allows them the flexibility of using different types of hardware that can in turn affect the layout and design of the room.

As I said at the beginning, a lot of the talk from the consultant’s standpoint was very technical and filled with jargon, so my biggest task was trying to infer the design implications for all the components discussed. This meeting really started reinforce the idea that you should know exactly what technology is going in the room in order for it to fit seamlessly into the room. Otherwise, things will be added on and it will look like the tech was an afterthought.

Properly preparing for these technical components requires attention to detailing and specifying conduit, ductwork, blocking in the walls and floor that can accommodate the anticipated tech.

Boston Children’s has a large media wall in the lobby that is one-of-a-kind and custom made for the hospital. This is a big landmark and interaction point for children in the lobby, helps to distract them during waits, and enlivens the lobby area. The Children’s hospital also hosts the Seacrest Studios by Ryan Seacrest, and patients are able to stream that media from their room with the patient entertainment system. The director of A/V emphasized how much infrastructure work was done to upgrade and accommodate most of these network connections throughout the hospital.

Discussion with Staff

4:00 pm

Currently the design for the new Waltham building

by Payette requires two separate rooms for IT and Low Voltage. The square footage required for these rooms is taking up a lot of space on the floor plate and poses some issues. The consultants talked about how there is a possibility for these rooms to be combined, which would reduce the square footage and hopefully resolve some issues. I saw once again

the idea that you need know now exactly what you’ll have to accommodate with the design and what flexibility it will afford you.

It was interesting to hear some staff members voice their opinions that they think TVs in patient rooms will go unused because patients and their families will uses tablets and smartphones. There was another comment that certain buttons and switches are placed close to the patient bed, but only staff, not patients, use them. Therefore, they could move to free up the head wall. So not only do you need to know the constraints of the components you will be designing with, but also so will be the ones actually using the components.

Staff voiced concerns about wanting to see more tech that caters to the patient, visitor, and staff experience. Family control and experience is another factor they would like to see improved. They mentioned the desire to have some outlet on the wall in order to connect your smartphone or tablet to the TV, but this seemed like such an outdated technology to me. Apple TV and Chromecast devices have become mainstream for wirelessly casting your devices to a TV. I can only imagine this technology will become more prevalent in five years when the project is scheduled to finish. BCH has a wayfinding app for patients and visitors, but the app is another form of technology I questioned since I personally hate downloading apps unless I know I will be using it frequently. The last piece of innovative technology that the team discussed was motion sensors around the bed to prevent patient slips and falls.

Inpatient room in the new addition with a med. gas boom

Overall Evaluation This shadowing opportunity was one of the most informative for me. I knew technology played a large role in healthcare delivery and management, but I severely underestimated its influence on design.

Even though I did not observe many patient-provider interactions, the interactions observed between care providers and technology was invaluable. I learned that the mess of cables around most workstations and pieces of equipment in the healthcare setting are avoidable if the designer can anticipate them. I also feel that I was able to take away some insight and knowledge about the technology different departments use that will come in handy during my professional work.

One of the biggest improvements I think can be achieved by a thorough technology consideration is the correct placement of outlets and switches. As I mentioned in the report, certain switches were placed by the patient that were actually used by staff.

Staff would also benefit from higher placed outlets if they are constantly having to plug and unplug equipment.

Decentralized charting stations outside of rooms with signage above

UP

UP

UP

DN

Exam

Exam

Exam

Trauma

Exam Exam

Staff Support

CT

Exam X-ray

Exam

Triage

Exam

2.4 | OBSERVATION 4

Boston Children’s Hospital Emergency Department June 29, 2016 9 hours

Intro Following my IT Walkthrough at Boston Children’s, I had the opportunity to shadow the Emergency Department. One of the architects at the office highly recommended it because they said the head of the department, Michele Morin, had a lot to say about the layout and design of the department.

I tried to take what I had learned from the IT observation and see how much technology was influencing the layout and operation of the department. I was very much looking forward to this observation since I knew it would be faster paced and not as repetitive as my past shadowing experiences. I would like to note that due to the level of activity and number of patients I was interacting with I was unable to take many pictures because of HIPPA concerns.

Individual trauma room in the department

Waiting

7:55 am

Once again I had the opportunity to walk to the hospital to start the observation. Much like my walk to Brigham and Women’s, their is not much pedestrian guidance for getting to the hospital. Most of the signage is more geared towards cars and traffic circulation. However, unlike BWH, Boston Children’s just has one public entrance and not multiple competing for attention.

The entrance to the ED is right next to the main entry of the hospital therefore they share the same vehicle drop-off. I’m sure this helps for those arriving by car because they don’t have to figure out which vehicle entrance to go to. The thing I liked most about the entry is that it is all glass looking into the waiting room. I was unsure exactly where I was suppose to go or who to talk to, but it relaxed me a little as I was able to see in and get a feel for where things were in the waiting area before I even walked in. I’m sure this sense of comfortability translates to patients and family too as they come in. They get a small primer of what they are about to experience before they fully engage with it.

One of the several different exam room layouts

Walkthrough of the ED

8:00 am

I started my observation by doing a walkthrough of the entire department with Michele Morin who is the head of the department so I could get a good sense of the layout of the dept. What Michele enjoyed showing me was the variety of room types and sizes they have in the dept. The ED has been added on to and renovated over the years so there will be groups of rooms that are similar, but then next to it is another group with a different layout and size. Some of the rooms were grandfathered in so they would not meet current code requirements for size minimums.

The big problem for staff is that cabinet/storage, light switch and sink locations are all in different spots in the different room groups, so it may cause them to take a second and remember where everything is in the room. Michele mentioned too that while some rooms have ample storage, the size and orientation of the storage is not ideal for what they will be storing in them.

They have space for three trauma beds; two beds is in one larger room and a third bed in a separate room right next to the main trauma room.

The third room has a sliding door that opens directly

8'-3"

7'-4"

19'-11"

12'-7"

11'-11"

11'-4"

104 ft2

87 ft2

225 ft2

Room Type 2

Room Type 3

Room Type 1 Different room sizes and layouts in the department

to the larger room so staff can flow back and forth in the event of a disaster. The main trauma room has large med. gas booms that Michele thinks take up too much room and makes the room too tight for two beds. The booms also look unsightly with cords and equipment hanging all over them.

There are a few types of specialty rooms throughout the department. Michele showed me a couple isolation or infection rooms that don’t make any sense in relation to the rest of the plan because they are in the back of the department. A very sick patient would have to walk all the way through the department to get to them. There is also a dental room at the front of the department, but the odd shape of the room causes the nurse call to be just out of reach of the chair. There is also a dedicated x-ray and CT in the department.

I encountered a somewhat funny experience when a father walked out of a room holding his daughter, and then looked around and said “I don’t know the way out”. It was slightly funny, but brought to light a potential problem of the department that might be worth trying to study throughout the day.

The main nurse’s stations and charting areas are concentrated at the center of the department.

They are fairly narrow and crammed with workstations. The arms of the chairs prevent them from going under the countertop so they take up more room in the charting area than necessary. The charting area also has maybe a 4’ partial wall with glass above it. I am not sure how crucial visibility is from this station, but you can only see over the wall if you are standing which seemed a little odd to me.

As Michele and I finished our loop around the department, we ended up back at the front of the department near triage. Triage and reception are located right inside the front entrance of the Emergency Department. There is also a desk for a security guard. Triage itself is small and composed of a vitals alcove, standing height counter for charting, and four separate rooms for triage assessment. After assessment, the patients will go either back to the main waiting area or taken back to a room. Michele mentioned that they will do full registration and insurance either at the bedside with an administrator or during discharge. The administrators typically hang out in the hall of the ED with WOWs that they could take in to the patient room.

9'-9"

98 ft2

99 ft2

Room Type 4

Shadow with Nurse

10'-0"

10'-1"

10'-10"

10'-1"

9'-2"

101 ft2

Room Type 5

9:00 am

After Michele showed me around, she introduced me to Katie who would be the nurse that I would shadow for the rest of the day. Since it was the very beginning of her shift, Katie was not yet tending to any patients so she was prepping for the day. This type of work goes on in a small workroom next to one of the main nurse’s stations. This workroom has four workstations in it, and then later on another nurse was using a WOW to work in the room. We started by going to the room of a mother and her children who were homeless and had spent the night at the hospital. A nurse or doctor was already in the room making a video call to an interpreter with an iPad on a rolling pole. The interpreter helped Katie and the other staff member figure out what the mother and children would like for breakfast. Instead of a regular bed, the two small children were sleeping in a large crib in the room. Katie and I then went to the main supply / support core for the staff so we could get some soap, toothbrushes, and toothpaste for the family to use.

Room Type 6

Ortho Procedure

10:00 am

At 10:00, I had the opportunity to sit in on an ortho procedure where they were setting the bones of a fractured arm and then putting on a cast. There was a small fluoro machine in the room for them to ensure they set the bones correctly. Before the procedure began, there were quite a few people in the room.

The patient was sitting on a chair that centered in the room, but towards the back. His father was in a chair next to him reassuring him about the procedure.

Then there was me and five other staff members.

The father left and a nurse gave some anesthesia to put the patient to sleep. A nurse adjusted the recliner he was on after he was asleep so it laid out flat. One thing to mention about the procedure room was that it was much hotter than the rest of the deptartment.

As soon as I went in wearing a full lead vest I began to sweat. Almost all of the staff in the room made sure to point out how hot it was and that it was the only room like this. Two people were on the side of the patient pulling his arm to set it, one staff member worked the fluoro, one was by the door charting everything, and another was just sitting in for any necessary assistance. They set the arm quickly and

Type 3

Type 2 Type 1

Type 6 Type 4

Type 5

Location and grouping of various room types

began putting on the cast. This was when I noticed that I was beginning to get very lightheaded from the heat. I sat down, but then realized I needed to get out of the room or I may pass out. I excused myself and Katie was nice enough to get me some juice and crackers and had me sit down for a little bit. I definitely became the butt of a few jokes after that for the rest of the day. Overall, though I felt like the size of the procedure room worked pretty well for the number of people and the equipment needed for the procedure. The only thing that seemed not to work was the A/C because it was so hot in the room.

Patient #1

10:30 am

After the ordeal with ortho room, we had a child come in on a stretcher in his car seat. A nurse took the child and a family nurse into a room and Katie began collecting information from the mother just outside the door of the room about the child. The child had some chronic issues, but had a fever lately that had not gone away. The mother was pretty demanding and rude at first; she seemed to know what was best since they dealt with these chronic issues. It was

obvious she knew a lot about her child’s illness and everything, but was being quite abrasive to Katie.

I noticed some WOWs charging in the hallway while this was going on and they were plugged into outlets mounted at about a foot and a half off the ground. It made me wonder about placing outlets at a higher elevation to make it easier for staff to plug in. Then as I began thinking about it, I wondered why outlets were placed so low in an environment like this to begin with. What is the benefit of having the outlets so low?

A clinical assistant (CA) brought in a scale and some other equipment to take vitals for the child while Katie was still talking to the mom and taking down notes. The bed was up against the wall, which Michele mentioned they prefer because they rarely need to be on both sides of the bed. I found this interesting because it was as if they came to a decision about how they would work as a department, and then once they decided the beds were able to be up against the wall giving the room more space. As opposed to the department leadership saying, well typically beds are in the middle, so we will just do that and have less space to move around. I assume any new staff members just got use to how they

operated after that and it has not caused any issues.

Department Comments There are a few characteristics and components that I wanted to be sure to highlight about the department that weren’t necessarily part of any particular experience. There is a small pharmacy in the department that makes it convenient to get medications to patients. There were also a lot of supply carts and other types of equipment just out along the hallway for nurses to access right before going into a room; a type of decentralized storage.

The department is divided into several teams, each assigned a different color. Teams are assigned a different group of rooms, and they come in at staggered times to account for staff leaving.

However, if a team’s rooms fill up, they will have to expand into another team’s rooms.

Each of the rooms have a binder in a wooden holder attached to the door. The binders contain patient information, and I would like to see these become better integrated into the design.

Otherwise it’s just something that was stuck on as an afterthought. Finding a way to tuck it away would help to ensure the privacy of the patient’s information also.

Patient #2

11:30 am

The next patient I visited with Katie was a young boy that had been having stomach pains for a while and the family was unsure what the issue was. The interesting thing about this visit was that the boy and his family were in a behavioral health room, though he did not have any behavioral issues.

Several aspects of this behavioral room did not work well. The room had a roll down door, but the walls bumped out where the rails were causing the bed not to sit flush with the wall. In addition, the very small countertop on the other side of the door was hardly big enough for Katie to place her clipboard on it. The countertop was so small in order to make it fit behind the roll down door when it was down. The room also seemed very dim, but after visiting some other rooms, it almost seemed to be a choice for

the families to keep the rooms dimmer than I would have expected.

The mother was sitting on the foot of the bed while the father stood and the younger brother sat on a chair opposite the bed. There were two other chairs in the room but they both held bags the family brought. It made me wonder if designers should provide some storage or cubbies for families in a children’s ED since families typically bring things to keep kids occupied. There was a TV mounted high on the wall that the patient and his younger brother were both watching. The room was tight with Katie and me both in the room. I was curious if the room could still be a behavioral health room but designed in such a way that it is more inconspicuous. We had looked at examples where the roll down door comes down along a counter and closes off everything at the counter. Katie mentioned that she wished the rooms had windows, especially behavioral health, because she thinks it would help calm the kids.

Katie went back to the workroom to chart some things before prepping and IV for the child. I began to realize that even though Katie is up and moving a lot, this small work area was her home base. Anytime she was not directly dealing with things for patients, she would be here working. Katie prepped the IV on a small cart outside the patient’s room and pulled the supplies from a locked cart in the hall; one of the “decentralized” carts I mentioned earlier. A patient that I did not get to visit was going to have to go get chest x-rays. Katie was able to raise up the stretcher to put the IV in easier. After the IV was in place and she took blood sample, Katie went out into the hall to use a WOW to scan the samples and then put them in a pneumatic tube capsule to send to the lab.

I asked Katie and another nurse in the workroom about the make-up of the teams, and they said that there are usually 2 – 3 nurses, a clinical assistant, and a doctor covering roughly 12 rooms There are 53 rooms in the department, so essentially 4 teams are needed to cover the whole dept. I then left to get a quick lunch and thought it was a little funny, but also sad, that Katie and the other nurse were eager to know what the weather was like since there are no windows in the department.

The layout of the department did not seem bad so far from what I had seen. Katie does not seem like she is running all over the place, it is just a back and forth going from her work area to the

Bed unable to sit flush w/ wall

Corner sink and counter Rolling door

Dad

Brother Similar behavioral health emergency room at Emory Hospital

Patient

Nurse Mom Me

Bed pulled forward when door down Plan of the behavioral health room observed in the emergency department

rooms. However, that seems to be her personal preference for how she works and other nurses may prefer being up the whole time and just using WOWs. The biggest obstacle for staff seems to be the variety of spaces. Certain beds will only fit in the smaller rooms, and then where stuff is stored in different types of rooms varies so staff may have to hunt a little. I do find it interesting thought that even though the smaller rooms do not meet code and are allowed to be grandfathered in, they’re obviously still functional. Therefore, what does it say about code, that even if a room does not meet it, the room can still be functional and adaptable? Should the code be challenged at times? Better yet, can it even be challenged?

Before Katie went to lunch, she told another nurse about her patients and where they were with their care / treatment.

Ideal room design allows for the bed to rotate while the headwall is closed off Source: http://mcdmag.com/2014/05/todays-er-designing-efficient-emergency-departments-in-the-21st-century/#.V7IQ1igrK71

Triage

2:00 pm

I next went out to triage to observe for a while. The triage area consists of two registration cubicles, a standing height counter behind them, a vitals alcove off to the side, and then four triage rooms down a little hall that leads to the rest of the department.

The wall with the counter has windows that look out into the ambulance bay so they have some visibility for security and can know when patients are coming in. There was a 5th room opposite the other four but apparently the ceiling had fallen, and they said they didn’t like it because you have to take the patient kind of the opposite direction; it’s not “on the way”.

There was only one administrator checking patients in and they said that was typical unless it was busy, so the other cubicle just became wasted space.

A family walked in and a nurse welcomed them, they had them check in with the administrator and then the nurse took them straight back to a room. They did not use the vitals alcove and they said they typically would not if it is not busy just to cut out a step and do the vitals in the room. After they evaluated the patient, a clinical assistant took them straight back to a room since there was not a

PAT.

PAT.

PAT.

PAT.

WORK ROOM

PHARM

X-RAY

Nurse Flow Patient to X-ray Katie’s work flow represented in orange. The blue line represents the travel path of a patient who had to have a chest x-ray

wait.

I made a second evaluation of the waiting area while I was at triage, and I will say that it is a little confusing to determine whom you should talk to first. The check-in desk is just to the right as you come in, but as you enter, you are facing directly towards a security desk and another desk labeled “Communications Desk”. Therefore, if a nurse does not see a patient or family come in the patient may go to one of these other desks first. I did think that there was a lot of color and decoration in the waiting area that felt appropriate and did not seem too age specific. Almost in the center of the waiting area is a large column that has the potential to cause some visibility problems. The signage for the restroom seemed clear and evident for patients and family.

One of the nurses working triage commented that with their small and narrow space you had to have “a good dance partner”. The back counter where the nurses are working faces away from the front door though and there was one instance when a family walked in and neither of the nurses noticed, and I was stuck in this awkward stare down of the family looking at me and then me looking at the nurses and back to the family.

A pane of frosted glass right by the entrance blocks the view of the second cubicle and prevents the nurses from being able to make eye contact with patients sooner. The staff wants to be able to establish that connection and communication right away. The vitals area does face right to registration though, so if one patient is having their vitals taken and another is checking in, the patient checking in can see the other patient and possible overhear any confidential information.

Triage #3

Triage #4

View to Ambulance Bay Staff Work Area

To Department

Triage #5 (Ceiling fell while shadowing)

Admin. Cubicles Triage #2

Triage #1

Security Desk

Communications Desk

Restroom

Vitals

Bad visibility when entering due to frosted glass panel

Waiting

Plan of triage area off of waiting

Trauma

3:00 pm

While I was in triage, I did see two ambulances come in and wheel a girl in on a stretcher, and I was curious to find out what had happened. Katie came back from lunch around that time so I went back into the department with her. One of the doctors came over when we got back and said that she had been looking for me because the girl I had seen earlier was in the trauma room. I went into the two-bed room and the girl was in one of the bays with six staff members around the bed. A car struck the girl going 10 – 15 mph and now the team was just finishing an assessment of her. It was obvious something was wrong with her leg so they were working to stabilize it. The mother was in the room off to the side. They brought in an ultrasound to check her stomach and make sure everything seemed all right. The mother was talking to an EMT, there was a nurse by the door charting everything, and a doctor was working the ultrasound while everyone else was assisting however or cleaning up. The doctor saw nothing on the ultrasound so he began to scan the leg just to get a sense of things before they sent her to x-ray. He could tell from the ultrasound that she had fractured

her leg, but that seemed to be the extent of any major injuries. I noticed the medical team was not using the boom for anything during their treatment. They brought in a portable x-ray and I decided this was my cue to leave so I would not have to find a lead vest.

I met back up with Katie and told her about what I saw. I asked her about the booms and she said that she does not like them.

Patient #3

4:00 pm

I went with Katie to visit the room of a little girl who she was covering for another nurse that was at lunch.

The room was dim, but that appeared to be the parent’s choice. The girl had an IV pump and there was a large stroller in the room too. Pretty much the only room for Katie and I to stand was right inside the door or at the foot of the bed. Is there somewhere strollers can be stored, especially in a children’s ED where they would be more common? The strollers seem to take up an unnecessary amount of space.

At this point in the day, the commotion in the department had definitely picked up. More staff were starting their shifts so there began to be more bodies

Main trauma room with two bays

at the nurse’s station and the small workroom.

Katie moved over to a different workstation and was now covering a different set of rooms near the exit to the waiting room. These were the older, smaller rooms and she mentioned that there were typically utilized for fast track procedures. I wonder if staff decided to use them as fast track since they were smaller, or if that just happened to be how staff designated them. The area we were working in now was not a separate workroom, but just a counter space with workstations along the hall to the supply area, perpendicular to the corridor of the fast track rooms. Anyone walking by could realistically see the screens and any patient information. This location also did not give the staff working there great visibility of the main corridor or rooms that they were attending to.

Overall Evaluation Shadowing the Children’s emergency department was one of my best observation experiences. Other than the great variety of room sizes and layouts, I thought the department worked really well and

helped to create a great staff culture. I fully expected to find several flaws in the layout and staff having to walk long distances around the department. I felt like the workroom where Katie spent most of her time was closely located to the staff core, pneumatic tube, and exam rooms. I am sure not everyone has short distances while they work, but no one seemed to be all over the place, I was also pretty surprised by the fact that Katie used the workroom as her home base. I had this idea that emergency room nurses are just constantly moving around the department and were not able to have a central work area. The variety of room sizes also surprised me, it makes perfect sense that it would happen from subsequent renovations, but even the location of storage in the room was different. I wonder what benefit there would be to locating storage in similar areas in renovated rooms.

The other main critique that Michele had about the storage was that they are ill sized for what will be stored in them. It is a very similar problem to what I observed at Brigham and Women’s of an alcove not sized properly for a particular piece of equipment.

Kick

Supply Cart

Supply Cart

Supply Cart

C-Arm

Anesth.

Instr. Table

Anesth.

Cart

Surgical Table

Circulating Nurse Station

Supply Cart Instrument Table

Kick

Scrub Sink

2.5 | OBSERVATION 5

Boston Children’s Hospital OR Mock-Up Simulation July 12, 2016 4 hours

Intro Boston Children’s Hospital is currently in the process of completing two large projects, a new clinical building for the main hospital and an addition to their Waltham Campus. Shepley Bulfinch is designing the clinical building and Payette is designing the Waltham addition. In order to refine their designs, both firms have constructed mock-ups of their key treatment rooms in an office building in the Longwood Area.

I had an opportunity during the summer to watch a simulated operation in Payette’s proposed design for the Waltham operating rooms. The mock ups originally began as cardboard iterations, but the ones that were built when I was there for the summer had been done with studs and drywall. In all the various treatment rooms (inpatient, outpatient exam, pre / post-op, OR) most of the equipment was actually installed. I thought it was really great that they were able to do this because the little big of cardboard furniture just didn’t give off such a realistic presence. The following observations record my experience with the OR simulation and aspects I hope to be able to carry forward.

Group briefing outside of the mock up room

Simulation Prep

1:00 pm

Before the simulation began, everyone who would be participating met off to the side to receive a short briefing. A team of consultants who work with groups like this to brainstorm ideas and figure out workflow was in charge of the simulation at this point. A woman from the team told the operating group some information about the patient and the nature of the procedure. She then told them that the goal of this simulation was not to throw them curveballs or put them in a crash situation. Instead, the objective was to focus on the design of the room and aspects that were not working well spatially. The woman emphasized paying attention to the placement of equipment and movement of equipment through the room.

After this quick overview of the procedure and briefing about the simulation objectives, the surgery team moved into the OR for another quick orientation. The team was made aware of placement of various equipment locations, which side of the OR represented the clean core and which was the corridor. The simulation began once this overview was completed.

Staff prepping the room before the simulation

Simulation

1:45 pm

Everyone on the surgery team moved to his or her respective areas of the room once the simulation officially began. I found it extremely fascinating just to watch the team getting ready for the patient coming in and everything. The team got ready and helped each other into sterile gowns with an almost automatic flow. A couple nurses brought in an empty stretcher to get a feel for how easily it could go into the room since the computerized dummy was already set up on the operating table. The table was a specialty ortho table that had various adjustments on it to hold parts of the body in specific positions.

The simulation began a little slowly at first because it seemed like the team was not fully into it. However, this started to dissipate as the team got into the rhythm of things more. Some of the nurses began covering the “patient� with gowns and other coverings while the surgeon talked to the anesthesiologist about the procedure. The surgeon then ran through a quick confirmation of the patient and procedure after the dummy and equipment was ready. The surgeon was on the rights side of the patient, with a scrub nurse directly behind him

The surgery team works to stabilize the patient as his vitals begin to drop. Surgeon is standing out of the way.

handing him equipment that he needed. The surgery was going to be a hip procedure so they had a C-arm brought in to confirm certain things about the area they would be working. The C-arm was made of cardboard, but of course done at the actual size of the machine. The team began pointing out issues right away because the C-arm was going to have to roll over a cable from another piece of equipment.

Soon after this, the dummy began having complications as their oxygen levels dropped. The anesthesiologist took over at this point and was trying to direct the rest of the team from the head of the patient about what to do. One of the nurses went into the hall to retrieve a crash cart, which also had to cross over the cable laying on the ground. Things began to get hectic at this point, and the surgery had essentially stopped until the dummy patient was stable. The surgeon just stood out of the way for the time being until he felt that he could go back to his position.

Simulation Pause

2:45 pm

The woman from the consulting company decided to pause the simulation at this point in order to talk about issues the surgery team was already noticing.

Milly, the architect from Payette in charge of the OR design, gave an “oh god� look at this point. I later found out that she expected this pause to take the entire time and that the simulation was ruined.

She ended up being right. However, I thought the brainstorming and back and forth between the surgery team was just as beneficial to see. I felt like I would not get the advantage of making the surgery team talk about design issues if I had shadowed at an actual operating room procedure.

The discussion began with the surgery team writing down their comments on sticky notes that were then grouped together on the wall. The intention was to find overall problems as opposed to just reiterating the same smaller issue repeatedly.

One of the first topics of discussion was the isolation of the anesthesiologist at the head of the patient. All the equipment and booms made it a little difficult for someone to get back to her and assist her during the patient crash. The surgeon commented how they

Surgery staff discussing design successes and issues during a pause in the simulation

operate with a three-door layout at the existing BCH operating rooms. This third door allows someone to walk in at the head of the patient and straight to the anesthesiologist. The team commented that this not only makes access to the anesthesiologist easier, but also prevents people from crossing the sterile field.

Milly told me that the problem with the third door in the new design is that it falls right where the stretcher alcove is in the hallway. This alcove is necessary for DPH requirements.

Another big area of discussion was the location of the surgeon’s charting desk in the room.

It is currently along one of the long walls, while the charge nurse’s station is at the foot of the room. They thought the surgeon’s desk was in the way and taking up precious work room. However, the surgeon did appreciate that the stools for the desk were able to slide under the table and be completely out of the way. Someone questioned how often the surgeon uses the desk, and he responded that he uses it before operations so ideally he would not want it near the door. He said that he‘d be bumped by everyone coming in and out of the room if it is placed by the door. There was some long discussion about the ideal placement for this charting station, but in

the end, there was no consensus so Milly would have to study it further.

The last main point of discussion for the group was the placement of the booms in the room.

The room was set up with two booms, one on either side of the bed, and an anesthesia boom. A few of the staff members mentioned that the anesthesia boom could be located more towards the left side of the room and not so central. This was not a huge change, but it was good to see the impacts of how a team works on the design of a space.

View of the operating room mock-up

Overall Evaluation Even though I was disappointed I did not get to see the entirety of the operation simulation, I felt it was a great learning experience. The simulation gave me the ability to hear feedback directly from the users as they interacted with the space that they might otherwise overlook or not consider. The A+H studio will be working on an OR prototype for the coming semester, and this experience gave me several components to consider when working with the design.

The simulation also gave me some insight into the challenges that architects are faced with.

The surgery team from BCH is so accustomed to working in an OR with three rooms, that it has set the benchmark for what they expect in the new building.

As I mentioned earlier, this third door poses a major conflict for the design team because it would require moving stretcher alcoves in a lean surgery suite. This issue made me start wondering how you can try to find a middle ground of revising how the current staff work and preserving existing workflow models.

E.W.

FUME HOOD

Speciality Labs [Not Observed]

FUME HOOD

FUME HOOD FUME HOOD DESK DESK

FUME HOOD C84

E.W.

Blood Gas EKTACHEM N.I.C.

Urinalysis

Chemistry

Offices / Staff Support

FUME HOOD

E.W.

Lab Control

FUME HOOD

E.W.

Hematology FUME HOOD

Offices / Staff Support

2.6 | OBSERVATION 6

Boston Children’s Hospital Clinical Laboratory July 27, 2016 8 hours

Intro The decision to shadow the clinical laboratory came from heavy influence by Scott Rawlings and Susan Blomquist at Payette. Scott and Susan both believe it is the most overlooked or least understood department, by architects. The fact that Susan was the only one on the BCH Waltham design team that had any prior experience with designing a clinical lab reinforced their belief.

I had the chance to help Susan layout the clinical lab during the summer and I realized right away that her and Scott had a point. There were so many different complicated pieces of equipment to account for, and you would have no clue where they needed to be without prior experience. During my observation, one of the hematologist told me that the laboratory is responsible for a third of the income for the hospital. Whether or not he was completely accurate, the importance of the department still holds true.

4 Blood Gas Analyzers

P-Tube Coagulation Analyzer

Coag.

Work Area

To Lab Control

Blood Gas Tech Coagulation Tech Plan of blood gas and coagulation areas

Blood Gas

8:00 am

My contact for the lab, David Dumais, told me a little about the laboratory before I started my shadowing.

The lab is on the 7th floor of the building and sits in a renovated inpatient unit. David mentioned that because of this the layout of the lab and offices obviously is not ideal. Lab techs are not allowed to have drinks in the lab so they are stored in a metal cabinet down the hall from the lab. Another lab director, Stefanie, said the divisions between clean and dirty space is unclear because of the layout of the floor.

David took me into the lab after I put on a lab coat and took me to the Blood Gas area. I learned that blood gas is one of the most critical parts of the lab because the samples they test have a thirtyminute turnaround time. The areas has a dedicated pneumatic tube so samples are sent right to the lab bench and do not need to be transferred. Once the tech receives the sample, they will put it into one of the four blood gas analyzers on the bench. The tech also has a phone on the lab bench so she can quickly contact anyone if there are issues with a sample. The set up shown the plan above seems to work quite

Blood gas station

well and does not require the tech to move a lot during her demanding job. The main problem with this area is the tech will receive samples meant to go to Lab Control. The tech then has to walk all the way over to Lab Control to give them the samples. This has the potential to cause samples for Blood Gas to back up while the tech transfers samples. I realized right away that Lab Control and Blood Gas should really be co-located and that it is a major flaw of the BCH clinical lab.

Above the bench were some shelves with a bunch of maintenance binders for equipment. The area was also filled with various boxes and left over supplies. The tech said it was just a consequence of being in the corner of the lab where things collect. I began to realize there was no such thing as too much storage in the lab. The tech mentioned she would enjoy each tech having their own rolling cabinet where they could store personal items and easily take it around the lab with them.

The tech then showed me the two areas adjacent to Blood Gas. Coagulation is right behind blood gas and receives samples from the same pneumatic tube. The Coagulation workbench is quite small, but does not require a lot of space since

Samples from Lab Control

Allergy Lab Area

Rolling Supply Cart (Higher than Work desk)

Input Point

Chemistry Analyzer

Chemistry Analyzer Label Printer Input Point

Supply Containers

Work Area #1

Chem. Tech #1 Chem. Tech #2 Plan of the chemistry area

the tech is pretty much just putting samples into a large analyzer. Urinalysis was the other station next to Blood Gas. The Blood Gas tech pointed out that the benches for Urinalysis are separate and causes the techs working there to walk around more. The extra distance is not a ton, but strays from the idea of the workbench being similar to the “kitchen triangle� to increase efficiency. While the tech was showing me these stations, I noticed many of the cabinets had printed labels describing the contents inside.

I thought it would be nice to use some cabinets with integrated labels so they did not seem like an afterthought.

Chemistry

10:00 am

Chemistry was the next area of the lab I shadowed.

The section has its own little pod in the lab that consists of two large chemical analyzers in the center with lab benches surrounding them. One of the first things I noticed was how the shelving above the bench was better suited to the equipment manuals it held compared to the shelves in Blood Gas. One of the analyzers was undergoing quality control when I walked over, so a tech on the other analyzer was running all the samples. Samples were brought over from lab control, and then the chemistry tech would scan them and prepare them to be put in the analyzer. I thought the techs work area was set up very well. He was able to scan samples, prep them, and put them in and out of the analyzer by only taking a few steps. He could also do so by rotating around on his stool if he was sitting. I began to wonder about the location of Lab Control again since techs would bring samples to chemistry from control. Between the two chemistry analyzers is a gap that is filled with all the cables and tubing from the analyzers. It space was dusty and cluttered, and I believe that gap was required so someone could easily fit behind the

Lab tech processing samples in the chemistry area

machines for maintenance.

The ceilings in this space were extremely low, around 7’ 6�, but all the windows in the lab kept the spacing from feeling dark and crowded. Peter told me that sometimes he has to print new labels on the test tubes because the machine has trouble reading the original labels. For years, the techs would have to go to a label printer to print a new one, but they recently installed one at the chemistry workbench.

The tech said that this saves them a lot of time.

As I moved over to shadow the tech and the other chemistry analyzer, I noticed that there was a large pieces of equipment that was blocking a refrigerator door The work area for the other chemistry analyzer is different and less efficient than the other one. The work surfaces are much smaller and split into two areas. The workspace with the computer is on a movable desk and is at a sitting level. The sample prep area is right behind the tech while at the computer and is at a standing height. Therefore, the tech working this analyzer has to go between the two stations, stand up, and sit down. The tech working at this analyzer thinks that eye level is important.

She cannot easily see the rest of the Chemistry area

while sitting and the computer. She also pointed out that even though the other tech’s area is laid out better, he faces the corner and has bad visibility.

From this desk, I was able to get a better view of the main corridor in lab, and I liked that they had utilized the space between columns for storage. Behind this station was an analyzer and work area for allergies. I thought the area was in a very strange spot though and very separate from everything else in the lab.

I started to think about how these large chemistry analyzers started to dictate where workstations were placed in this part of the lab, and I wondered if Susan was considering this with her design. I hope to remember this when I have the chance to work on a space like this professionally.

I would hate for a space to sacrifice functionality because I was unaware where the tech would sit to operate the equipment. I also began to think about the overall layout of the lab. The BCH lab has a main corridor in the center that is double loaded, and I wondered if there would be a benefit to a single loaded lab. This would prevent techs from having to cross the busier circulation zone of the corridor.

A single loaded layout out could increase visibility across the entire lab unlike the columns that block

3.

Sample stain

2.

1.

Most samples stop here

Samples from Control

Wasted desk space

Countertop where samples are left for distribution

4a.

Further analysis if needed 4b.

4c.

Sample Flow Analyzer Tech.

Plan of the hematology area

views along the corridor of the current lab. However, I assume single loaded would create a longer lab and therefore adjacencies would be absolutely crucial. One of the lab directors did tell me that at the beginning of the day that movable furniture would be ideal for the lab. Equipment will move or change so being able to flex the workspace with the equipment maintains efficiency.

“Wasted� area between lab control and core lab

Hematology

1:00 pm

I moved to the Hematology area of the lab after shadowing Chemistry. Hematology is set up as a circle to flow samples through the area. A tech brings samples over from the sample holding area, put in an analyzer, and then moved on down the circle if they need further analysis. Otherwise, techs discard samples or send them back after the first analysis.

A tech was changing supplies in the hematology analyzer when I came over and they had to go down the hall to get the replacement. It seemed a little strange to me that refills were not placed closer to the machine. At the end of the analyzer, was lab bench space to stain and smear blood samples for study under the microscope. The samples move to a large desk where five hematologists have microscopes for further analysis. Each tech will focus on a particular aspect of the study. Two of these techs commented that they do not have room to put their legs under the desk at certain parts, which makes it harder to work. Movable cabinets below the counter would allow them to customize the workspace and let them adjust for comfortability.

Three of the techs sit at a round counter top

View of core laboratory from the entry of the lab

that allows them to easily collaborate and give input if another is unsure about a sample. However, this counter top was comically deep and ended up just being wasted space. I walked around this area a few times looking at all the equipment and I was shocked for how much dust was around the equipment for such a “clean� lab space. It seemed like Hematology, Urinalysis, and Blood Gas all benefit being next to each other because of overlap of equipment use.

There were a few additional comments I had about the space before leaving Hematology. The area where techs leave samples from Lab Control seems a strange because it is just a countertop towards the center of the lab. The space feels like it floats between the lab benches and lab control, and I could see how there is potential for samples to be misplaced. The other comment came from one of the lab directors who said that often the auxiliary equipment is an afterthought. Equipment such as sharps containers, glove boxes, trash cans, and biohazard containers.

Lab Control

3:00 pm

I shadowed Lab Control for the rest of the day after lunch. The layout of the space is shown above, but describing what happens at each space will help to understand the flow of samples through the department. Samples either arrive through the pneumatic tube or runners drop them off. Techs enter the samples into the system at workstations to the left, and one tech will process samples brought in by runners by the pass-through window. Once the samples are entered into the system, the techs hand them off to another tech working several centrifuges at the center of the room. This tech spins and organizes samples based on the analysis they require. The bench with the centrifuges is compact and allows the tech to process samples quickly and efficiently. Samples are sent into the core lab once they are spun, or they are placed in refrigerators / freezers next to the centrifuge bench.

The workspace at the top right of the plan is where a tech will package samples that need to be sent out to a specialty lab. At the bottom left of the plan is a small workroom for billing that Matt, the director of Lab Control, should be in a separate office. There is

2.

Sample Distribution

4.

Pass-Thru Window

Billing + Paperwork

1.

Processing / Receiving

FUME HOOD

Shipping / Packaging

Cooler Storage

Freezer + Refrigerator

“Wasted Space�

Processing / Receiving

E.W.

3b.

P-Tube

Spinning (Centrifuges)

3a.

Flow of samples through lab control

a space dividing Lab Control and the core lab that seems wasted on supplies and trash. Can this type of space be on the periphery instead of increasing the connection between the two essential components?

I found the casework for the centrifuge area interesting because the center of the tabletop was recessed. This configuration allowed the tops of the two centrifuges to rest at the same level as the rest of tabletop. I am sure this type of counter makes the work flow a little easier for the tech, but I wonder if this is a standard piece of equipment and something the architect knows about. I also that Lab Control is victim to the same problem that plagues every department I shadowed during the summer. This problem is papers just taped to walls all over the room as opposed to being on tack boards or bulletin boards.

I learned from someone in Lab Control that the clinical lab is going to move to the basement once the new clinical building is complete at the main BCH campus. This move is a real shame because sunlight and views out to Mission Hill and the rest of the medical campus calms the busy environment of the lab. Overall, the layout of the Lab Control space works well. The only characteristic that I think could

improve is the orientation of the pneumatic tube.

The tube station currently faces towards the core lab, and I believe the techs entering the samples would benefit from the tubes facing north on the plan. The techs would have a shorter distance to walk. The only other area for improvement would be better storage, but I am unsure what would be the best method for providing additional, flexible storage.

I was unsure if it was just the time of day, but the Lab Control is noticeably busier and faster paced than the core lab. I assume this is because all the samples have to go through this area, and then separate and disperse to the different areas of the core lab. However, I was curious what implications this might have on the design. If the designer is unable to achieve an ideal layout, should lab control be the top priority for maintaining ideal efficiency?

I also thought the placement of the refrigerators and freezers worked well because anyone who needed to access them for core lab could do so without having to cross paths with the Lab Control techs. I saw the tech from the Blood Gas area come in several times to drop off samples while I was shadowing in this area. I knew she had to walk to Lab Control to transfer samples that she received by accident, but I did not

Bench where samples are spun in lab control

realize she had to walk all the way across the room to the techs entering the samples into the system.

It is a much longer distance than I anticipated. In contrast to the distance the Blood Gas tech had to walk, a runner came in the room and went straight to a workspace by the techs entering samples and unloaded more samples. The runner was in and out quickly without having to cross paths with anyone else in the room.

Overall Evaluation I really enjoyed having the opportunity to shadow the clinical lab because it was so apparent that adjacencies are critical. While certain adjacencies worked well in the BCH clinical lab, the lab is too compartmentalized overall. The lab adapted well to a space that was not originally intended for it, but still has many flaws. The most significant adjacency is the relationship between Lab Control, Blood Gas, and the rest of the laboratory. I received the impression that these two parts should be centrally located in the lab. I now understand the advantage of providing flexible and movable furniture in the department in order to allow the lab to adapt efficiently to new or changing equipment.

3.0 OVERALL E V A LU AT I O N

3.0

Overall Evaluation I documented several reoccurring themes during my observations this summer. I would like to finish this report not with an evaluation of the individual hospital departments, but with the major lessons learned from this opportunity. All of these lessons are ideas I hope to hold on to as I complete my final year of school and also use them in professional practice.

They will only help to strengthen my projects and perhaps provide insight that other professionals may overlook The most reoccurring problem I witnessed during my shadowing was the issue of storage and designing for specific equipment. This seems like a very obvious lesson that most architects should be aware of, but it is the more insignificant, support equipment that is the victim. The best example was the crash cart alcove in the BWH Rad Onc department that was not designed large enough to accommodate the bumper rail around the bottom of the cart. As a result, the cart is unable to be stored in the appropriate spot and now there is essentially a wasted space. The other main example of this issue within healthcare design is the design of cabinets and storage within treatment rooms. The Boston Children’s emergency department is a good example because of the variety of storage they have in their exam rooms. Sometimes the storage was designed for what needed to be in there, but otherwise supplies were crammed into cabinets or shelves that are too small. Staff would also modify storage spaces to better hold supplies. One of their improvised methods that I thought worked very well from a functional standpoint, is a wire grid on the wall with adjustable hooks. Hooks for supplies could then be rearranged to better accommodate different sized supplies much like retail displays. I was fortunate to see some of this design thinking at Payette when one of the architects designed some custom shelving for an imaging room that they made sure would be large enough to fit the equipment that would be stored such as gloves and surgical masks. I

think it is a valuable design ideology that may cause you to have to do some deeper research into how the staff works and what supplies they need, but I think it will only contribute to them enjoying their workspace even more.

The Children’s emergency department also provided me with an overarching question as opposed to a definitive lesson learned. Michele Morin made a point of showing the issues that arise from different sized rooms with different storage locations. This idea made me begin to wonder how much architects take into consideration the current layout of spaces from and efficiency and functionality standpoint. Of course renovated spaces should reflect best practice design ideas, but that might mean completely moving storage from where it is in the older rooms. I definitely want to explore this idea moving forward with school and look at this idea of achieving best practice standards, but also being sensitive about current workflow and layouts.

In my mind, this type of consistency could only help to maintain staff efficiency and functionality.

To counter this point, there was a discussion this summer at work about the benefits of same-handed and mirrored patient rooms. People brought up the point that same-handed rooms have everything in the same place which makes it easier for staff, and then one of the principals in the room retorted / joked that he was, “under the impression that nurses were smart people.” He felt that storage being in different locations was not that much of a challenge for most people, especially highly educated staff.

Transitioning from outside specific rooms to the department as a whole, I began to notice what could be considered the functional core of the departments I shadowed. There were certain areas of each department that were the busiest and acted as the heart that all other areas depended on. In the emergency department it was the main nurse’s station, in the clinical lab it was both lab control and blood gas. I think it is important that architects recognize these areas in every department so when sacrifices have to be made in design, these areas remain unaffected. Negative impacts to these department drivers trickle down as operational and functional deficiencies in other areas of the department. I also think it is the adjacencies for these cores that should be established and maintained first to further improve the efficiency of the department.

The clinical lab demonstrated inefficiencies that

occur when core areas are split such as lab control and blood gas.

My observation experiences also taught me the reality of how much staff are moving around during the day. I guess since we have discussed reducing the amount of steps staff take I was under the impression that staff are constantly moving around. I observed staff moving around a lot more in certain departments of the hospital, but I was surprised to see how often staff would be sitting at a workstation just working. The lab techs in the clinical lab rarely left their own station, the radiation therapists would only leave the control room to bring a patient in from waiting or to prep the radiation vault, and the emergency room nurses sat in a workroom when not helping patients. Similar to the previous lesson learned, the architect should be aware of where these staff members are spending their time and locate them adjacent to treatment areas.

These staff work areas should be separated just enough to keep patient information private and secure however. I am sure the staff are not too worried about it becoming a problem, but from a strictly HIPAA standpoint I think things can be done better.

There was the example of the physician workstation in the Radiation Oncology waiting that any patient could see leaving one of the OTV rooms. Additionally, the vitals area was right next to the registration area of the Children’s emergency department. Patients could overhear sensitive information between the nurse and patient in the vitals alcove. There were also several instances of curtains installed after construction because monitors with patient information were too visible from hallways. I think this is a very simple fix and requires the designer to think not only about where workstations are located, but also the range from which the monitors are visible by staff or patients passing by.

The last lesson learned developed from my multiple observations in the Brigham and Women’s Radiation Oncology department. This lesson was that the flow that seemed to create the most inefficiencies was the flow of inpatients. I believe it is just because the staff is having to move these patients since they tend to be in stretchers or wheelchairs. Staff who would be otherwise prepping the treatment space for outpatients have to instead go and retrieve inpatients. This reduces the amount of staff able to complete work, but also requires additional time for them to retrieve the patient. At

BWH, this was an obvious flaw because the inpatient holding area was not centrally located to the exam and treatment rooms. And then there were issues of only one exam room being able to easily accommodate a stretcher (which was also the exam room furthest from inpatient holding). I think this is a harder problem to since it is inter-departmental, but it was one of the main causes of staff having to walk long distances and longer treatment times. It definitely made me rethink the flow of departments.

The flow is no longer the patient coming from waiting to the treatment room, but the staff member having to go to waiting and then back to the treatment area.

All of these lessons learned are invaluable to my development and growth as a healthcare designer. They are all lessons I do not think I would have realized without the opportunity to shadow care providers on site. It was an extremely beneficial opportunity and I was glad to hear positive feedback about the observations from both hospital staff and architects. I hope to be able to spend time shadowing in my professional career to better understand certain departments, or perhaps departments where I have no previous experience. The process goes a lot farther than just relying on what staff tells you about work flow, but truly shows you what is critical to them and how they work in their space. I also believe it helps to create a relationship between the staff and architects, and develop a sense of trust that the architect better understands how staff works.