RIPCHD.OR Volume 1 by Clemson Center for Health Facilities Design & Testing

AF107 - OPTION C4

THE CIGAR FACTORY | OR MOCKUP

701 East Bay Street, Charleston, South Carolina 29403 | Clemson - Suite 130

[DRAFT] NOT FOR CONSTRUCTION

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OPTION MATRIX

AF108 - OPTION D1

AF106 - OPTION C3

AF109 - OPTION D2

FRAME D

AF104 - OPTION C1

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AF105 - OPTION C2

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Sheet Issue Date 160829

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Mockup design

Design development & implemenattaion at MUSC

2018

2016

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Literature review Case Studies OR observations

2017

2015

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Testing & evaluation

CARE THROUGH HUMAN-CENTERED DESIGN IN THE OPERATING ROOM RIPCHD.OR

VOLUME 1 | 2015-2016

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This project was supported by grant number P30HS0O24380 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the offical views of the Agency for Healthcare Research and Quality. EDITORS: Anjali Joseph, Deborah Wingler & David Allison

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EDITORIAL ASSISTANTS: Herminia Machry, Rachel Matthews & Sara Bayramzadeh

GRAPHIC DESIGNERS: Deborah Wingler, Rachel Matthews, Rutali Joshi, Leah Bauch, Hannah Shultz

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g TABLE OF CONTENTS n i t s Te 01 Project Overview

01 - 17

Literature Review

18 - 49

03 04 05 06 07

Flows

50 - 59

Case Studies

60 - 73

Procedure Maps

74 - 93

Advisory Committee

94 - 99

Whatâ&#x20AC;&#x2122;s Next

100 - 105

Surgical Suites Operating rooms Equipment & instruments Tools & technology Materials Air ventilation Auditory conditions Thermal conditions Lighting Visibility

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Realizing Improved Patient Care through Human-centered Design in the Operating Room RIPCHD. OR

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Two to five percent of all patients who undergo an operation will develop a surgical site infection leading to significant mortality and morbidity. The incidence of adverse events such as surgical site infections and surgical errors are an immense problem in the OR due to the highly vulnerable state of the patient and the complex interactions required between providers of different disciplines. Distractions and interruptions are major causes of medical errors during surgery and often lead to serious harm for patients. Additionally, the wide range of equipment used to perform procedures, rapidly changing technology and the physical space where care is provided pose challenges to providing high quality care. Clemson University and the Medical University of South Carolina (MUSC) were awarded a 4-year grant from the Agency for Healthcare Research and Quality (AHRQ) to develop a safer and ergonomically sound operating room. The Realizing Improved Patient Care through Human Centered Design in the OR (RIPCHD.OR) learning lab proposes a comprehensive approach to contemporary OR suite design. A multidisciplinary team comprising of architects, human factors, operations researchers, simulation experts, anesthesiologists, nurses and patient safety experts are working collaboratively on RIPCHD.OR projects. This project integrates research, studio teaching and practice components through the course of the project with the goal of developing design ideas that can be implemented and evaluated in operating rooms at MUSC.

PROJECT AIMS

PROJECT FOCI

The RIPCHD.OR learning lab will be conducted in four main phases over 4 years (September 2015 – August 2019). Specific aims of this project include:

2017

02 Mockup design

Design development & implemenattaion at MUSC

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2018

2016

2015

Literature review Case Studies OR observations

Testing & evaluation

UNMASKING OF ANESTHESIA-RELATED ALARMS AND COMMUNICATIONS

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1. Formally structure the RIPCHD OR learning lab and establish laboratory infrastructure and team management. 2. Develop a systematic approach to evaluating the impact of people, tasks, tools and technology and the built environment in developing ergonomic and human-centered operating room design solutions. 3. Develop process design recommendations to support key OR flows (OR team members, supplies, patient, equipment, information) that impact patient safety outcomes such as surgical site infections and surgical errors. 4. Develop evidence and recommendations related to the use of advanced displays and multimodal displays for anesthesia tasks to mitigate the masking of important signals. 5. Develop an evidence-based framework and methodology for designing operating rooms that achieve the desired patient and staff safety outcomes. This project will integrate the findings and recommendations from all three proposed projects.

PROJECT PHASES

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This work extends what is known about alarms, interruptions, and distractions in the operating room by examining them from a systems perspective.

PROJEC

TRAFFIC FLOW AND DOOR OPENINGS IN THE OR This project will focus on understanding factors impacting trafﬁc ﬂow in the OR suite.

INTEGRATED OR SUITE DESIGN PRO

JECT

This project aims to develop an overall framework and methodology for designing an ergonomic and human-centered operating room that will improve patient and staff safety and outcomes in the OR.

PROJECT FRAMEWORK

Medical devices, Electronic medical records, Supplydevices, carts, Booms, Medical surgicalrecords, lights, Electronic medical communication Supply carts, Booms,tools, surgical lights, alarms communication tools, alarms

WORK SYSTEM

t en m t en m Organization

PROCESSES

OUTCOMES

PROCESSES

OUTCOMES Organizational

Technology and Tools Technology and Tools

Organization

Organizational

Professional Work Professional Work Collaborative Care Team Patient Work Collaborative Care Team Patient Work Patient Work

Person Person

Job demands, variety of tasks challenges and Jobutilization demands, of variety skills, work of tasksdensity, challenges and workﬂow utilization of skills, work fragmentation, etc. density, workﬂow fragmentation, etc.

Care Team

Tasks

Environment

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Environment

Patient

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Enviornmental hazards, ADAPTATION Study framework for RIPCHD.OR learning lab is based on layout, noise, lighting, the SEIPS 2.0 framework by Holden and colleagues 11 Enviornmental hazards, temperature, humidity, ADAPTATION Study framework for RIPCHD.OR learning lab is based on (1) American Society of Anesthesiologists. (2013). Statement on principles for alarm management for anesthesia professionals. layout, noise,station lighting, 11 air, work design, (2) American College of Surgeons National Surgical Quality Improvement – Pediatric Data User Guide. (2014), Page 21, Variable deﬁnitions for duration of anesthesia, duration of patient in OR,and totalcolleagues operation time the SEIPS 2.0 framework by Holden temperature, surgery humidity, table, alarm, (1) American https://www.facs.org Society of Anesthesiologists. (2013). Statement on principles for alarm management for anesthesia professionals. (3) Mears, S.C., Blanding, R., & Belkoff, S.M. (2015). Door opening affects operating room pressure during joint arthroplasty. Orthopedics, 38(11), e991-e994. http://www.healio.com/orthopedics/journals/ortho.pdf air, work station design,etc. (2) American doors, storage, College of Surgeons National Surgical Quality Improvement – Pediatric Data User Guide. (2014), Page 21, Variable deﬁnitions for duration of anesthesia, duration of patient in OR, total operation time (4) Polites, S.F., Habermann, E.B., Zarroug, A.E., et al. (2015). A comparison of two quality measurement tools in pediatric surgery – The American College of Surgeons National Surgical Quality Improvement Program – surgery table, alarm, https://www.facs.org Pediatric versus the for S.M. Healthcare and Quality Pediatric Quality Indicators. Journal Pediatric Surgery, 50, 586-590. readinghttp://www.healio.com/orthopedics/journals/ortho.pdf the discussion section, which recommends examining pediatric surgical site (3) Mears, S.C., Blanding, R.,Agency & Belkoff, (2015).Research Door opening affects operating room pressure during joint of arthroplasty. Orthopedics, 38(11),After e991-e994. doors, storage, etc. infections, since it is the most common complication following pediatric surgical procedures, other than transfusion; recommend that we look at orthopaedic cases.

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(4) Polites, S.F., Habermann, E.B., Zarroug, A.E., et al. (2015). A comparison of two quality measurement tools in pediatric surgery – The American College of Surgeons National Surgical Quality Improvement Program – (5) American College of Surgeons National Surgical Quality Improvement – Pediatric Data User Guide. (2014), Page 21, Variable definitions for number of superficial incisional SSI cases, days from operation until superficial Pediatric versus the Agency for Healthcare Research and Quality Pediatric Quality Indicators. Journal of Pediatric Surgery, 50, 586-590. After reading the discussion section, which recommends examining pediatric surgical site incisional SSI complication https://www.facs.org infections, since it is the most common complication following pediatric surgical procedures, other than transfusion; recommend that we look at orthopaedic cases. (6) Palmer, G., Abernathy, Swinton, G., & Arch, M. (2013). Realizing Improved Patient through Operating Room Design. of Anesthesiology, 1-12. SSI cases, days from operation until superficial (5) American College of SurgeonsJ., National Surgical Quality Improvement – Pediatric Data UserCare Guide. (2014),Human-centered Page 21, Variable definitions for number superficial incisional (7) American Collegehttps://www.facs.org of Surgeons National Surgical Quality Improvement – Pediatric Data User Guide. (2014), Page 21, Variable definitions for duration of anesthesia, duration of patient in OR, total operation time incisional SSI complication https://www.facs.org/ashx G., Abernathy, J., Swinton, G., & Arch, M. (2013). Realizing Improved Patient Care through Human-centered Operating Room Design. Anesthesiology, 1-12. Education, experience, (6) Palmer, (8) American Academy of Pediatrics and The American Academy of Pediatric Dentistry. (2011). Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic College of Surgeons National Surgical Quality Improvement – Pediatric Data User Guide. (2014), Page 21, Variable definitions for duration of anesthesia, duration of patient in OR, total operation time certification, skills, know-(7) American procedures. http://www.aapd.org/media/policies_guidelines/g_sedation.pdf https://www.facs.org/ashx Education, experience, (9) Polites, S.F., Habermann, E.B., Zarroug, A.E., et al. (2015). A comparison of two quality measurement tools in pediatric surgery – The American College of Surgeons National Surgical Quality Improvement Program – ledge, physical and (8) American Academy of Pediatrics and The American Academy of Pediatric Dentistry. (2011). Guideline for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic Pediatric versus the Agency for Healthcare Research and Quality Pediatric Quality Indicators. Journal of Pediatric Surgery, 50, 586-590. After reading the discussion section, which recommends examining pediatric surgical site certification, skills, knowhttp://www.aapd.org/media/policies_guidelines/g_sedation.pdf psychological character- procedures. infections, since it is the most common pediatric surgical procedures, other than recommend that we look at tonsillectomy cases. Surgical Quality Improvement Program – (9) Polites, S.F., Habermann, E.B., Zarroug, A.E.,complication et al. (2015).following A comparison of two quality measurement tools in transfusion; pediatric surgery – The American College of Surgeons National ledge, istics, physical and (10)versus CDC (2011). The National Surveillance System for Healthcare Workers Summary for Blood and Body Fluid Exposure Data Collected from section, Participating Facilities (June 1995 through cognition Pediatric the Agency for Healthcare Research and Quality Pediatric Quality (NaSH): Indicators. JournalReport of Pediatric Surgery, 50, 586-590. After reading the discussion whichHealthcare recommends examining pediatric surgical site psychological characterDecember https://www.cdc.gov/nhsn/pdfs/datastat/nash-report-6-2011.pdf abilities, etc. infections, since it(2007) is the most common complication following pediatric surgical procedures, other than transfusion; recommend that we look at tonsillectomy cases. (11)(2011). HoldenThe R. 2013. SEIPS 2.0: A Human Factors Framework for Studying andSummary Improving the Work of Healthcare and Patients. Ergonomics. 56 (11), 1669-1686. (10) CDC National Surveillance System for Healthcare Workers (NaSH): Report for Blood and BodyProfessionals Fluid Exposure Data Collected from Participating Healthcare Facilities (June 1995 through istics, cognition December (2007) https://www.cdc.gov/nhsn/pdfs/datastat/nash-report-6-2011.pdf abilities, etc. (11) Holden R. 2013. SEIPS 2.0: A Human Factors Framework for Studying and Improving the Work of Healthcare Professionals and Patients. Ergonomics. 56 (11), 1669-1686.

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Care Team

Patient Work Tasks

1 1 2 2

PROCESS

PROCESS OUTCOMES

OUTCOMES

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WORK PROCESS OUTCOMES OUTCOMES Specify SYSTEM anesthesia work station Specify processes to unmaskPROCESS Anesthesiologist/nurse anesthetist Organizational Outcomes: ANESTHESIAand technology design alarms or mitigate the responds in a timely fashion (Look at -Duration of anesthesia 2 RELATED ALARMS & interventions UNMASKING -Duration in OR to unmask of masking organization’s Alarm Management Organizational Specifyeffects processes to unmask Anesthesiologist/nurse anesthetist Specify anesthesia work stationalarms Outcomes: 1 ANESTHESIACOMMUNICATIONS and technology design alarms or mitigate the responds in a for timely fashion (Look -Duration of anesthesia -Total OR time 2 or mitigate the effects of masking Policy a definition of thisat parameter) RELATED ALARMS & interventions to unmask alarms in OR of cases per OR per day effects of masking organization’s Alarm Management -Number to critical physiologic changes (O2, -Duration COMMUNICATIONS or mitigate the effects of masking Policy for a definition this parameter) 1 -Total OR time ETCO2, NIBP, of HR, etc.) -Number of cases per OR per day to critical physiologic changes (O2, intervention - Fewer incidents of delayed ETCO2,toNIBP, HR, etc.) in physiologic measures critical changes - Fewer incidents of delayed intervention Minimize frequency and duration of Patient Outcomes: PEMSI FLOWS IN OR Specify design and process Identify and mitigate the to critical changesthe in physiologic measures door openings to improve air quality 3 interventions to help minimize factors contributing to -Number of SSI for orthopedic cases 4 5 Minimize the frequency and duration of Patient-Time -Number of door openings PEMSI FLOWS IN OR Specifydoor design and process Identify andopenings mitigate the Outcomes: openings and flow door to SSI 3 door openings toofimprove quality -Number minutesair door open per case factors contributing to interventions to help minimize -Number of SSI for orthopedic cases 4 5 disruptions -Number of door openings -Room pressure mean inches H2O -Time toCare door openings and flow door openings SSI Team Outcomes: -Number of minutes doorwith open<0 per case -Number of cases pressure disruptions -Team member satisfaction survey scores -Room -Percent pressure of mean H2O timeinches case in line with Care Team Outcomes: -Number of cases with <0 pressure regulatory air pressure standard -Team member satisfaction survey scores Organizational Outcomes: -Percent of time case in line with -Cost reduction – avoidance for SSI regulatory air pressure standard Organizational Outcomes: -Regulatory Survey pass -Cost reduction – avoidance for SSI Use a systems approach to Identify the factors that Minimize flow disruptions in five -Regulatory Operational Outcomes: Survey pass analyze patient, equipment, impact flow and cause categories: 6 - Duration of anesthesia 7 Use a systems approach tostaff and Identify the factorsand that disruption, modify Minimize materials, supplies, flow disruptions Operational Outcomes: - Duration in OR - Usability related in five 6 7 analyze patient, equipment, impactprocesses flow and cause information accordingly categories: - Duration of anesthesia - Total OR time - Layout related materials, supplies, staff and disruption, and modify - Usability related Duration in OR - Number of cases per OR per day - Environmental hazards information processes accordingly - Layout related - Total OR time - Interruptions - Environmental hazards Number of cases per OR per day - Equipment failure - Interruptions - Equipment failure Minimize impacts of flow disruptions PROJECT UNMASKING

WORK SYSTEM

Externa l En Externaviro l Enn vir on

Teamwork coordination, collaboration, work schedules, management Teamwork coordination, style, on-time collaboration, work preformance, etc. schedules, management style, on-time preformance, etc.

WORK SYSTEM

PROJECT

3 3

Patient Outcomes: Develop a framework Minimize Enhance the of the impacts of performance flow disruptions - Number patients transferred or admitted (concept of operations surgical team Develop framework theof performance ofChecklist the Patient Outcomes: to the hospital orafunctional program) Enhance - Use Safe Surgical (concept of describes operationsevidence surgical team patientsoftransferred or admitted - Number cases of surgery on the wrong that - Prophylactic IV antibiotic timing - Number or functional program) - Use of Safe Surgical Checklist to the hospital patient, site or side and best practice that describes evidence - Prophylactic IVworkflow antibioticwithin timing the team - Number of casesofofadverse surgery events on the wrong - Number associated processes in the OR Improve and best practice patient,with site or side for GI procedures 8 sedation processes in the OR Improve workflow withinof the team of adverse associated - Incidence of events ortho SSI Enhance visibility work and team- Number with sedation forpost-operative GI procedures 8bleeding for - Intra and members Enhance visibility of work and team - Incidence of ortho SSIpatients 9 tonsillectomy members - Intra and post-operative bleeding for Minimize distractions of team members 9 tonsillectomy patients Care Team Outcomes: Minimize distractions of team site members Reduce risk of surgical infections -Number of OR staff needle/sharp injuries Care Team andOutcomes: blood and body fluid exposure 10 Reduce risk of surgical site infections -Number of OR staff needle/sharp injuries -Number of OR staff trips, slips, falls and and blood andinjuries body fluid exposure 10 other -Number of OR staff slips, falls and *Improve OR trips, efficiency other injuries - Number of cases/day/room/specialty *Improve OR efficiency - Number of cases/day/room/specialty Table developed by Eileen Malone for the RIPCHD.OR learning lab Design an ergonomic and INTEGRATED OR human centered OR SUITE DESIGN Design an ergonomic and INTEGRATED OR human centered OR SUITE DESIGN

Table developed by Eileen Malone for the RIPCHD.OR learning lab

Literature & Review

Data Collection

Coding & Data Analysis

IRB Approval: - IRB approval was obtained in December 2015 through MUSC’s IRB for year 1 activities that involved human subjects, including video recordings of surgeries as well as focus groups.

Bacterial Load Sampling: - Sampling was conducted during 16 of the recorded surgeries, which are being analyzed separately from the rest of the recorded videos due to possibe variations in behavior prompted by the loud noise of the air sampling equipment.

Advisory Committee: - The technical advisory committee has been formally established. - Met with the RIPCHD.OR project team in person at Clemson University to share their progress to date and obtained feedback on project direction and focus

Discrete Event Simulation Model: - The team is developing a prototype discrete-event simulation model that will enable the team to analyze the PEMSI ﬂows that occurred in the videotaped surgeries. - A key outcome will be to identify the density of occupancy within each region or zone within the OR and the frequency of common paths used within the OR.

AUG ‘16

Case Studies: - The team has conducted case studies at two surgery centers in addition to MUSC to get a broader perspective about OR suite design, including possible alternative and best practice layouts, ﬂows and designs. -The two facilities that were visited included Bellevue Surgery Center in Seattle, WA and the Surgical Services at Spartanburg Regional Medical Center in Spartanburg, SC. -Case study methods included interviews with staff, observations and in-depth assessment of OR and surgical suite areas to map ﬂows and OR design features.

Operating Room Mock-Up: -The team identiﬁed and obtained high quality mock-up space that meets project speciﬁcations. - In addition, a strong baseline of information has been developed to support a mock-up design and development, including obtaining an extensive equipment list that will inform the acquisition of needed equipment. - The team is also working to determine design and equipment needs to construct an OR mock-up.

AUG ‘16

APR ‘16

MAR ‘16

MAR - MAY ’16

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Development of Anesthesia Workstation Simulator: - Construction and development of software to run a simulator of an anesthesia workstation that will be used to support work in year 2 - We evaluated display technologies for their potential implementation into the simulated workstation for experimentation in year 2.

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Data Analysis: - Use of qualitative and quantitative methods to examine and interpret the data from the videos -The coding process yields in-depth quantitative data on location and activities of all key players in the OR. -Use of simulation software will support the development of heat maps for each observed surgery, allowing the team to understand the usage of space at different phases of the surgery and potential zones that need to be redesignedfor more efficient and safe surgery. - The heat maps will also allow the team to visualize the relationships between OR space usage at specific points in time and location of surgical flow disruptions. - Additionally, all the data from the Noldus software as well as bacterial load sampling is being moved to SPSS, as coding for surgeries is being completed to facilitate in-depth analysis to answer research questions.

APR ‘16 ONWARDS

Coder Training: - Process to train coders through the development of a coding guide as well as multiple rounds of pilot training to ensure understanding of surgical processes observed and consistency across coders - Changes were made in stages to the codes and coding process to ensure the best outcomes.

Behavior Observations of the OR System: - Remotely watching videos of 51 recorded MUSC surgeries using Noldus Observation Labs software -Three surgeries were used to pilot data collection and analysis in order to test the video recording set up and coding process.

FEB - MAY ‘16

JAN - APR ‘16

Literature Review: - An in-depth literature review was conducted on operating room factors associated with patient safety from the perspective of each project team. The focus was on understanding the relationships between systems’ components, and on identifying key outcome metrics associated with patient safety.

JAN - APR ‘16

- An observation protocol was developed that would allow the team to understand patterns of use in the OR according to deﬁned categories: Subjects, Surgery, Phases, Locations, Activities, and Equipment and Tools. - Coding for the potential/actual impact of ﬂow disruptions in the OR, using a framework developed by Parker et al (2009) -Observing door openings in the OR from the video recordings as well as duration of door openings will be used to understand the impact of door openings on disruptions as well as bacterial contamination in the OR.

DEC ‘15

SEPT - DEC ‘15

Problem Analysis and Coding Protocol:

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JUN E ‘16 ONWARDS

This has been an incredible first year for the RIPCHD.OR learning lab. Our accomplishments range from coming together as a coherent and functional team to building a strong knowledge base and shared understanding about the operating room environment. While we focus here on the specific research tasks that were accomplished as part of this project, the importance of developing this team structure cannot be emphasized enough, especially given the diversity of team member locations as well as diversity of disciplines represented. One of the key goals for this year was to build a study framework and systems view of the people, processes, tools and technology, as well as the built environment in the OR, ultimately looking at potential impacts on safety. This study framework would also serve as the foundation for future design, development and iterative testing phases. The key activities accomplished this past year included:

JULY ‘16

PROJECT ACCOMPLISHMENTS | YEAR 1

Focus Groups: - Two sets of focus groups were conducted with surgical team members at MUSC to obtain user input regarding barriers and facilitators to shed light on the observed behaviors as well as to highlight any key areas for future study and development.

RESEARCH CONTEXT The RIPCHD.OR learning lab conducted an in-depth examination of existing operating rooms at the Medical Univsersity of South Carolina‘s campus in Charleston, South Carolina. The research teams observed procedures in operating rooms in two buildings on the MUSC campus to understand current surgical processes, technology and physical environmental conditions. This will help inform the development of future phases of RIPCHD.OR as well as support the design decisions for two future ambulatory surgical centers – one pediatric and the other orthopedic – being planned at MUSC.

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MUSC CAMPUS

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ASHLEY RIVER TOWER OPERATING ROOM LOCATION

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Circulating Nurse Work Station Surgeon’s Work Station Foot of Surgical Table Surgical Table Zone 1 (right side of patient or head of patient)

Surgical Table Zone 2

(left side of patient or head of patient)

Door to Sterile Core Door to Corridor Transitional Zone Anesthesia Work Station Zone Supply Zone Support Zone

MAIN HOSPITAL OPERATING ROOM LOCATIONS

LOCATION ZONES INSIDE THE OPERATING ROOM

NORTH

CORE TEAM The core team comprises of the principal investigators and co-directors of the learning lab (Dr. Joseph and Dr. Reeves), Dr. Turley from Health Sciences South Carolina (HSSC) as well as individual project team leads. Their role is to oversee the overall administration of the project and support collaboration between project teams. Each of the three projects are led by two project leaders - one from Clemson University and the second one from MUSC, such that efforts between the two key collaborators are closely coordinated. Members of the core team are supported by a research coordinator and program coordinator.

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ANJALI JOSEPH | PH.D., EDAC CLEMSON UNIVERSITY

CHRISTINE TURLEY | M.D.

SCOTT REEVES | M.D.

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MARK SCHEURER | M.D.

MEDICAL UNIVERSITY SOUTH CAROLINA

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MEDICAL UNIVERSITY SOUTH CAROLINA

DANIELLE SCHEURER | M.D.

HEALTH SCIENCES SOUTH CAROLINA

DAVID ALLISON | FAIA, FACHA CLEMSON UNIVERSITY

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JAMES ABERNATHY | M.D.

DAVID NEYENS | PH.D., MPH

KEVIN TAAFFE | PH.D.

JAMES McCRACKEN

MEDICAL UNIVERSITY SOUTH CAROLINA

CLEMSON UNIVERSITY

SARA BAYRAMZADEH | PH.D. CLEMSON UNIVERSITY

CLEMSON UNIVERSITY

PROJECT 1 | UNMASKING OF ANESTHESIA-RELATED ALARMS & COMMUNICATIONS RESEARCH QUESTIONS

TEAM 1 is working to extend what is known about alarms, interruptions and distractions for anesthesiologists

in the operating room from a systems perspective. The three aims of this project have the goal of developing and evaluating systems design methods that account for masking and exploring interface design as a means to mitigate the effects of masking.

SPECIFIC AIMS AIM 1

Identify displays and alarms that can be presented in different sensory channels and the potential patient safety consequences associated with specific alarms by conducting observations in the OR and conducting focus groups with clinicians.

AIM 2

Evaluate alternative display designs for information and alarms in Aim 1 by designing and experimentally testing the perceptual aspects of displays that incorporate alternative information presentations (e.g., heads-up displays, tactile displays and gestural displays).

AIM 3

Evaluate how these display strategies would integrate into the new OR suite mockup for anesthesiologists and other OR personal by conducting focus groups and anesthesiologist user evaluations.

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How does task switching affect the anesthesia vigilance tasks?

How do tasks differ between induction, maintenance and emergence?

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PROJECT TEAM

DAVID NEYENS

SARA RIGGS

KEN CATCHPOLE

KATIE JUREWICZ

What are the perceptions of the anesthesia team and other surgical team members of displays and alarms?

Identify how do anesthesiologists interact with displays and other equipment?

How are information and alarms susceptible to masking and how can technology counteract the effects of masking (e.g., heads up displays, tactile displays, gestural displays)? SCOTT BETZA

How can continuous information be effectively presented to anesthesiologists (e.g., heads up displays, tactile displays, gestural displays)? 13

PROJECT 2 | TRAFFIC FLOW & DOOR OPENINGS IN THE OR RESEARCH QUESTIONS

TEAM 2 is focused on understanding factors impacting traffic flow in the OR suite. The team is studying PEMSI

flows (i.e., Patients, Equipment, Materials, Staff and Information) using a systems approach. The factors impacting traffic flow and distribution will be analyzed to develop solutions that will minimize door openings and flow disruptions in the OR. Microbial load data is also being collected and analyzed.

AIM 1 AIM 2

Use PEMSI workflow/coordination measures to identify control mechanisms.

AIM 3

Test/develop workflow practices using both computer simulation and live simulation.

AIM 4

Identify how physical constraints of OR design affect PEMSI workflows.

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PROJECT TEAM

How does the coordination of staff (and their PEMSI workflows) support the timely and safe delivery of surgical care?

SPECIFIC AIMS Develop performance measures of PEMSI workflows in the OR and measures of coordination between these workflows.

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KEVIN TAAFFE

LAWRENCE FREDENDALL

YANN FERRAND

DEE SAN

KUNAL BHIDE

BRANDON LEE

DOTAN SHVORIN

CASSANDRA SALGADO

ROSS HARRIS

What are the workflow control mechanisms that lead to improved coordination among staff?

How can we predict the effects of control mechanisms so as to inform the design of effective control mechanisms? How do the PEMSI flows affect the level of contaminants and microbial load in the operating room?

How can staff behavior be changed to reduce the number of door openings?

How can the OR be designed to facilitate the PEMSI workflows? 15

PROJECT 3 | INTEGRATED OR SUITE DESIGN RESEARCH QUESTIONS

TEAM 3 is working to develop a better understanding of how different aspects of the operating room built

environment interact with other OR systems factors such as people, equipment, tools and processes to impact patient and staff safety in the OR. The team works closely with other project cores to integrate the three projects, determine optimum procedure room configuration, identify optimal orientation and intra-room zoning that supports performance, improve workflows within surgical teams, enhance the visibility of work and surgical team members, minimize distractions of team members and reduce the risk of surgical site infections.

SPECIFIC AIMS AIM 1

Determine how different aspects of the operating room built environment impact patient and staff safety.

AIM 2

Design and evaluate through an iterative research-design-evaluate-redesign process.

AIM 3

Integrate the findings and recommendations from all three RIPCHD.OR projects into a proactive OR safety risk assessment framework.

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How does the design of the OR contribute to patient and staff safety outcomes?

What is the Optimal OR size for ambulatory surgery?

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PROJECT TEAM

ANJALI JOSEPH

DAVID ALLISON

JAMES ABERNATHY

DEBORAH WINGLER

HERMINIA MACHRY

SARA BAYRAMZADEH

LEAH BAUCH

RACHEL MATTHEWS

RUTALI JOSHI

ZAHRA ZAMANI

BILL ROSTENBERG

HANNAH SHULTZ

What is the best OR layout configuration in terms of relative location of different zones? Can the OR be designed to support optimal and efficient workflows?

What are the important sightlines for the surgical staff?

What are the concerns related to lighting design?

What are the high traffic zones in the OR?

Do high traffic (crowded) areas contribute to surgical flow disruptions (SPDs)? And to specific types of SFDs?

Are there activities or locations that are associated with SFD? Or precede SFDs?

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AIR VENTILATION AUDITORY CONDITIONS

EQUIPMENT & INSTRUMENTS

THERMAL CONDITIONS

TOOLS & TECHNOLOGY

LIGHTING

MATERIALS

VISIBILITY 19

SURGICAL SUITES

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A â&#x20AC;&#x153;surgical suiteâ&#x20AC;? is a functional procedural service area where surgical services are provided and usually includes an amalgamation of rooms within it, including procedure rooms, clinical support spaces, patient support spaces, and administrative support spaces (Rostenberg & Barach, 2012). The design of the surgical suite has great potential to improve the quality of patient care, patient safety, and overall efficiency. One of the key goals of the surgical suite design is to achieve efficient and safe maneuvering and flow for patients and staff as well as instruments, materials and equipment, and supplies (clean and dirty). Maintaining a clean environment in the OR to reduce risk of infections is also a key design driver that impacts surgical suite design. Different assumptions around separation of clean and dirty flows (e.g., physically separat and shared) have resulted in different types of surgical layouts. However, no studies were found that evaluated the relative benefits of different types of layouts from an efficiency or infection control standpoint. A few studies have explored the potential benefits of parallel processing (performing surgery related tasks such as instrument set up or induction in a different space at the same time the surgery is being conducted in the OR/procedure room) on efficiency outcomes such as turnover times and OR utilization.

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LITERATURE

DESIGN CONSIDERATIONS

EFFICIENCY

SURGERY SUITES

Parallel processing: • Induction rooms outside the OR can reduce non-operative time and increase OR utilization by almost 9%. [1] • Individual induction rooms work best for short procedures, while centralized induction rooms support longer procedures more cost-efficiently. [2] • Two induction rooms per surgical suite can maximize operational efficiency, decreases space and equipment requirements and increases flow. [3] • Parallel induction flow can increase patient throughput by decreasing non-operative time from 67 to 38min., which is almost a 5% reduction in operating time. [4]

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Storage and space constraints: • Space constraints can reduce access to patient and equipment during unexpected emergency care [7] • Surgical suites equipped with adequate storage and wide corridors can improve efficiency, while reducing clutter and potential patient injuries. [8]

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Space for new equipment and technology to be incorporated into the surgical

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Open plans that allow for operational changes and technology upgrades

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Adjacencies: • The proximity of the OR in relation to the post-operative and equipment storage impacts intra-operative efficiency. [5, 6]

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Ample storage for diagnostic imaging equipment within, between ORs, or near the OR

Space that is isolated from building systems vibration Ample electrical and data capabilities Ample air handling capacity Reduced travel distance between pre-operative, post-operative, and OR areas

for staff and patients

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Reduced travel distance for surgical team members during surgeries

the procedure room

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Maximize visibility between team members

rooms based upon staff task and needs

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Technology that supports coordination between pre-op, post-op, and OR staff

Placement of control rooms that does not require imaging staff to cross through

Adjacencies of support areas such as central sterile, pharmacy and sub-sterile

Surgery type: • Minimally Invasive Surgery suites (MIS) can increase time efficiency by 3-4 minutes. [9]

REFERENCES

CASE STUDY CONCEPTS SEATTLE CHILDREN’S BELLEVUE SURGERY CENTER • • • • •

OPPORTUNITIES • • •

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[2] Marjamaa, R. A., Torkki, P. M., Hirvensalo, E. J., & Kirvelä, O. A. (2009). What is the best workflow for an operating room? A simulation study of five scenarios. Health care management science, 12(2), 142-146.

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[3] Pelly, N., Zeallear, B., Reed, M., & Martin, L. (2013). Utilizing integrated facility design to improve the quality of a pediatric ambulatory surgery center. Pediatric Anesthesia, 23(7), 634-638.

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Evaluate the potential efficiency benefits of parallel processing for ambulatory surgery given the short duration of surgeries. Evaluate benefits of induction rooms for pediatric surgery at MUSC. Develop simulation models for potential surgery center configuration based on understanding of actual behaviors in space.

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[1] Torkki, P. M., et al. (2005). Use of anesthesia induction rooms can increase the number of urgent orthopedic cases completed within 7 hours. Anesthesiology 103(2), 401-405.

Dual induction rooms leverage parallel processing to increase throughput by having all preoperative assessment and induction take place in the induction room concurrently while another surgery is being conducted. Layout supports single flow through the system, reducing patient and staff travel distance. Standardization of supplies and equipment in each room provide efficiencies for staff. Natural light from the corridor filters through translucent panels in the door of the induction room to provide natural light as well as overhead lighting. Lighting in the ceiling outlining clouds provides a positive distraction for children during induction while providing soothing ambient lighting.

[4] Sandberg, W. S., Daily, B., Egan, M., Stahl, J. E., Goldman, J. M., Wiklund, R. A., & Rattner, D. (2005). Deliberate perioperative systems design improves operating room throughput. Anesthesiology, 103(2), 406. [5] Gurses, A. P., Kim, G., Martinez, E. A., Marsteller, J., Bauer, L., Lubomski, L. H., . . . Thompson, D. (2012). Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Quality & Safety, 21(10), 810-818.

[6] Healey, A., Sevdalis, N., & Vincent, C. (2006). Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics, 49(5-6), 589-604. [7] Hirsch, R. (2008). The hybrid cardiac catheterization laboratory for congenital heart disease: from conception to completion. Catheterization and Cardiovascular Interventions 71(3): 418-428. [8] Kenyon, T., Urbach, D., Speer, J., Waterman-Hukari, B., Foraker, G., Hansen, P., & Swanström, L. (2001). Dedicated minimally invasive surgery suites increase operating room efficiency. Surgical Endoscopy, 15(10), 1140-1143. [9] Bang, C. (2014). Planning and design of progressive healthcare facilities. Architecture Research, 4(1B), 2731.“

OPERATING ROOM

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SIGNIFICANCE

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The operating room is a very high-risk, problem-prone patient care environment. The dynamic medical technology and clinical practice in the operating room has been changing rapidly. Increasingly, diagnostic and imaging capabilities are being incorporated in the surgical domain, and procedures and surgical practices are transitioning from mostly open procedures to techniques that are less invasive and more equipment intensive. There are many new players and sub-specialties involved in providing care in the operating room. The use of a range of equipment and technology places varying demands on building systems and space requirements. Patients are highly vulnerable in this setting. A few studies exist looking at specific aspects of the operating room design such as airflow and acoustics, and its relationship to safety outcomes such as surgical site infection and surgical errors. Other aspects of the operating room physical environment such as clutter from cables and tubes, intra-room zoning, location of storage, sightlines and OR lighting also potentially impact patient and staff injuries in the OR though the impacts of these design features have been less researched.

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Staff Satisfaction

Patient Safety

Efficiency

LITERATURE

DESIGN CONSIDERATIONS

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STAFF SAFETY

• Doors with automatic touch panels reduce accidental or unintentional door opening and closing [1]

□□ Space that can accommodate varying surgical table positions □□ Space to accommodate additional personnel during the surgical procedure □□ Space that can easily accommodate integration of new procedures and their associated technology Increased structural load capability to accommodate booms in varying configurations □□ Varying levels of ambient light □□ Ample storage for interventional and diagnostic equipment in side OR □□ Provide a minimum of three distinct lighting types: general ambient light during procedure, focused and precise procedural light for incision and sterile field, and high levels of room illumination for induction and turnover. □□ Workstations for nurses and clinicians that allow visual and auditory monitoring of surgical procedure □□ Workstations that are ergonomic and fit nurse and clinician tasks □□ Defined zones for circulation, sterile tasks, and anesthesia that are free of unrelated through traffic □□ Placement of doors to direct flow away from anesthesia work area and sterile zone □□ Integration of equipment into ceiling mounted booms to minimize needs for moveable equipment, cables and associated clutter □□ Noise reduction strategies for building noise (ventilation) and voices

• Falls in acute cares (including ORs) were related to slippery/uneven floors, inadequate space or clutter due to improper storage [2]

STAFF SATISFACTION

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• Thermal ventilation, lighting, equipment operation, equipment positioning, as well as comfortable postures and layout conditions in the operating room can increases surgical staff satisfaction, health and comfort [4]

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• Inadequate OR size, lack of horizontal space for storage, non-standard work spaces and inappropriate

positioning of equipment or tools can result in clutter that impedes view, facilitates tripping and bumping hazard, and results in adverse patient safety events [5]

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• Most older ORs lack sufficient space for the amount of equipment needed for today’s surgeries [6] • Inadequate use of space or wrongful positioning of furniture and equipment were found to be the main causes of surgical flow disruptions associated with OR layout [7]

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• Most surgeons were found to prefer a window with a view to the outside [3]

PATIENT SAFETY

OPERATING ROOM

emperical grey user literature literature insights

CASE STUDY CONCEPTS

REFERENCES

SPARTANBURG REGIONAL MEDICAL CENTER

[1] Hirsch, R. (2008). The hybrid cardiac catheterization laboratory for congenital heart disease: from conception to completion. Catheterization and Cardiovascular Interventions 71(3): 418-428.

• • • • •

Recessed supply cabinets accommodate storage, while maximizing valuable floor space in the OR. The larger size of the OR area affords the inclusion of moveable diagnostic equipment within the operating theatre. Overhead booms and surgical table provide flexibility in positioning for multiple procedures, while reducing the amount of clutter on the floor. A fixed-base operating table reduces tripping hazards, enhances cleanability and facilitates quicker turnover times, while affording optimal positioning of the patient for procedures. The Neptune, a self-cleaning blood containment machine, reduces turnover time, enhances staff safety by reducing exposures to infectious materials and provides efficiency with waste removal.

[2] Drebit, S., et al. (2010). Occupational and environmental risk factors for falls among workers in the healthcare sector. Ergonomics 53(4): 525-536.

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Research is needed that tests different room sizes and intra-room zoning configurations to enable efficient movement within the OR. Understand the impacts of different layouts and equipment positioning on surgical team member sightlines and visibility through mock-ups. Evaluate flexibility of positioning monitors and lighting to support different types of procedures and also to reduce glare on monitors. Positioning of surgical table in relation to OR zones to support efficient flows. Evaluate impacts of different storage options of equipment, materials and supplies on surgical flow disruptions. The design and width of the door (swing vs. sliding) and impact on flow disruptions. Evaluate the position of fixed equipment within the room as it impacts accessibility for task performance for different team members. Understand the potential impacts of different equipment storage locations on surgical efficiency and flows.

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[3] Matern, U. and S. Koneczny (2007). Safety, hazards and ergonomics in the operating room. Surgical Endoscopy 21(11): 1965-1969..

OPPORTUNITIES • • • • • • • •

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[4] Dascalaki, E. G., et al. (2009). Indoor environmental quality in Hellenic hospital operating rooms. Energy and Buildings 41(5): 551-560. [5] Alarcon, A., & Berguer, R. (1996). A comparison of operating room crowding between open and laparoscopic operations. Surgical Endoscopy, 10(9), 916-919. [6] Albayrak, A., Kazemier, G., Meijer, D., & Bonjer, H. (2004). Current state of ergonomics of operating rooms of Dutch hospitals in the endoscopic era. Minimally Invasive Therapy & Allied Technologies, 13(3), 156-160.

[7] Palmer, G., Abernathy, J., Swinton, G., & Arch, M. (2013).

Realizing Improved Patient Care through Human-centered Operating Room Design. Anesthesiology, 1-12.

LITERATURE STAFF PERFORMANCE

EQUIPMENT & INSTRUMENTS SIGNIFICANCE

Staff Safety

Operating rooms are equipment intensive environments where a range of different equipment (e.g. ceiling mounted booms, monitors, computers, C-arms) and instruments are required to perform surgery. Some equipment is fixed and stays in the OR, while other equipment is moveable and is brought into the OR for specific procedures. The location and accessibility of both fixed and moveable equipment is a critical design consideration that impacts efficiency. For example, equipment in the OR may block a staff member’s path to their destination and require them to detour. Instruments may be disposable or reusable, and are usually brought into the OR prior to the surgery. The sterility of the instruments used during the procedures is critical and damaged or improperly cleaned instruments can pose a serious disruption to the surgery. The location of central sterile department in relation to the surgical suite and location of sub-sterile rooms in the surgical suite to allow emergency sterilization are critical design considerations that impact surgical flow and patient safety.

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• Equipment layout interference, ineffectiveness, unsuitable orientation, inadequate illumination and difficulty holding equipment produced discomfort. [1] This contributes to minor surgical failures and errors . [2] • Equipment in the OR produces clutter that impedes necessary monitoring or view. [4] • Ergonomically advanced (hand switch or foot switches for device activation) and automated equipment (use of voice control, touch screen to activate equipment outside the surgical field) is preferred by the surgeons. [1]

Staff Performance

STAFF SAFETY

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• Surgeons prefer two monitors; one positioned at eye level; front, and the other in operating field; front, rather than placing the monitors at 45 degrees to reduce neck muscle strain. [3] • Malfunctioning & inadequacy of equipment (Cables and tubes) increases slips, trips and falls. [1]

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ERRORS

• Visibility of the monitor helps in reducing errors for the nurse and surgeon. This depends on the height of OR tables and the correct positioning of Mayo stands.[5]

REFERENCES [1] Matern, U. and S. Koneczny (2007). Safety, hazards and ergonomics in the operating room. Surgical Endoscopy 21(11): 1965-1969.. [2] Arora, S., Hull, L., Sevdalis, N., Tierney, T., Nestel, D., Woloshynowych, M., . . . Kneebone, R. (2010). Factors compromising safety in surgery: stressful events in the operating room. The American Journal of Surgery, 199(1), 60-65.

Errors

[4] Gurses, A. P., et al., (2012). Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Quality & Safety, 21(10), 810-818. [5] Marcos, P., Seitz, T., Bubb, H., Wichert, A., & Feussner, H. (2006). Computer simulation for ergonomic improvements in laparoscopic surgery. Applied ergonomics, 37(3), 251-258.

[3] Matern U, Faist M, Kehl K, et al., (2005). Monitor position in laparoscopic surgery. Surgical Endoscopy 19, 436–440.

LITERATURE STAFF SAFETY

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• Surgeons preferred 3D glasses and 3D monitors as they were found to reduce errors. However, the use of monitors

TECHNOLOGY & TOOLS

caused neck and shoulder pain [1]

EFFICIENCY

SIGNIFICANCE

Staff Safety

[2,3]

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While there is little doubt that technological breakthroughs themselves have contributed to patient safety, an unacceptable number of avoidable patient safety incidents are resulting from the widening disparity between surgical innovation and the environment in which it is applied . The use of a range of equipment and technology places varying demands on building systems and space requirements. Some technological advancements in operating rooms include minimally invasive surgery, robotic surgery, sensors, wireless communication devises, and monitors.

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• Surgeons preferred electronically controlled tables with leg support or OR equipment with integrated voice control. • Surgical staff needs microphones and ceiling speakers, access to patient data / images, all controllable from one

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or multiple access points.The use of Electronic Checklist System (iECS) increases the duration of timeout verbal communication.[4]

• The sensors in key OR locations and RFID tags attached to surgeons help in retrieving information about the procedure phase, analyzing and assessing out of order steps causing procedural delays. [5]

REFERENCES [1] Brown SI, Frank TG, El Shallaly G, and Cuschieri A. (2003). Comparison of conventional and gaze-down imaging in laparoscopic task performance. Surgical Endoscopy, 17, 586 –590.

[4] Mainthia, R., et al. (2012). Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Surgery, 151(5), 660-666.

[2] Matern U, Faist M, Kehl K, et al (2005). Monitor position in laparoscopic surgery. Surgical Endoscopy 19, 436–440.

[5] Garbey, M., J. et al. (2015). An intelligent hospital operating room to improve patient health care. Journal of Computational Surgery, 2(1), 1-10.

[3] Patkin, M. (2003). What surgeons want in operating rooms. Minimally Invasive Therapy & Allied Technologies, 12(6), 256-262.

LITERATURE STAFF SAFETY

MATERIALS

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• Floor surfaces, monitors or keyboards, door handles, electronic devices, surgical light handles, circulating nurse area,

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and intravenous poles are highly contaminated surfaces in the operating room.[1]

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• Increasing the distance between the operating field and instrument table reduces contamination level around the

SIGNIFICANCE

wound. [2]

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Material selection is critical in the OR, as it impacts cleanability and potentially healthcare-acquired infection as well as the acoustical qualities of the room. Choice of material and location of the material in the room helps in reducing contamination through surface transmission. Some material has anti-bacterial properties and others are easier to clean. The types of non-porous materials that are easier to clean and typically used in the OR are usually hard sound reflecting surfaces and may contribute to reverberation and noise in the OR.

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• Irregular surfaces have higher colony counts. [3]

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REFERENCES [1] Alexander, J. W., Van Sweringen, H., VanOss, K., Hooker, E. A., & Edwards, M. J. (2013). Surveillance of bacterial colonization in operating rooms. Surgical Infections, 14(4), 345-351.

[3] Leest, L. V., Kawczynski, R., Lipp, F. E., & Barrientos, R. (2012). Identifying potential areas of infectivity on high-touch locations in the OR. AORN Journal, 96(5), 507-512.

[2] Friberg, B., Friberg, S., & Burman, L. (1999). Correlation between surface and air counts of particles carrying aerobic bacteria in operating rooms with turbulent ventilation: an experimental study. Journal of Hospital Infection, 42(1), 61-68.

LITERATURE PATIENT SAFETY

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• Laminar air flow has shown the lowest rate of contamination level impacting the surgical site, compared to

VENTILATION & AIR QUALITY

conventional, non-aspirating, and displacement diffuser .[1]

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• Contaminated air is released from the patients’ body and bounded by surgical staff and surgical light due to slow air

SIGNIFICANCE

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movement. [2]

Effectiveness of airflow in the OR is impacted by: ventilation, temperature difference, moving bodies, and surgical equipment positioning. The most common ventilation systems are turbulent, displacement, and laminar airflow (LAF). Turbulent and displacement ventilation systems are sensitive to movements (such as movement of people) that impact the creation of airborne contaminants. Laminar airflows can be vertical or horizontal. Vertical LAF is more effective in the operating room as it produces clear air directly over the operating table. However, there is no adequate empirical knowledge linking LAF to lower SSI.

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• Higher contamination levels are found around the surgical site, near the ceiling, and the lower part of the room .[2]

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• Functioning ventilation systems increased staff satisfaction and decreased work-related symptoms like dry skin, dry eyes, etc. [3]

Patient Safety

REFERENCES [1] Memarzadeh, F., & Manning, A. P. (2002). Comparison of Operating Room Ventilation Systems in the Protection of the Surgical Site. ASHRAE Transaction: Research, 108(2), 3-15.

[3] Dascalaki, E. G., et al. (2009). Indoor environmental quality in Hellenic hospital operating rooms. Energy and Buildings 41(5): 551-560.

[2] Ho, S. H., Rosario, L., & Rahman, M. M. (2009). Threedimensional analysis for hospital operating room thermal comfort and contaminant removal. Applied Thermal Engineering, 29(10), 2080-2092.

LITERATURE STAFF PERFORMANCE & SATISFACTION

AUDITORY CONDITIONS

surgeon which in turn affects task completion.[1]

• 84.1% of anesthetist, 65.6% of surgeons and 71.8% of nursing staff believed that noise has a negative impact on their

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SIGNIFICANCE

[1] Conrad, C., Konuk, Y., Werner, P. D., Cao, C. G., Warshaw, A. L., Rattner, D. W., . . . Miller, D. L. (2012). A quality improvement study on avoidable stressors and countermeasures affecting surgical motor performance and learning. Annals of Surgery, 255(6), 1190.

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The role music plays in the expert’s life may have a connection in their patterns of performance under different auditory

Staff Safety

High noise levels in operating rooms result in the need for louder alarms and voices for communication. Further, high decibel levels in ORs impede verbal communications that may result in errors and potential injury to the patient (Rostenberg & Barach, 2012). Increased noise levels are associated with short-term memory loss, damage auditory detection, and distraction during surgery (Patkin, 2003; Weinger & Englund, 1990). In addition, loud noises contribute to fatigue stress, higher blood pressure, and reduce task functioning for surgical staff, which may impact decision making during surgery .

REFERENCES

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• Auditory stress negatively impacts surgeons’ speed and accuracy with different levels of impact depending on the

Staff Performance

conditions.[3]

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• Loud noise causes increase in cortisol levels and stress. High noise levels in the OR has also been linked with noise-

Staff Satisfaction

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[2] Tsiou, C., Efthymiatos, G., & Katostaras, T. (2008). Noise in the operating rooms of Greek hospitals. The Journal of the Acoustical Society of America, 123(2), 757765.

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induced hearing loss in nurses and surgeons.

• Under noisy conditions of an operating room (average 77 dB), anesthesia residents reported decreased rates of mental efficiency and short-term memory [4]

EFFICIENCY • Major sources of noise were opening of doors, slamming of bins, loud conversations and falling or working equipments [5] • Sound levels for neuro and ortho surgery are high and sound levels in the OR were 30Db higher than the standard sound range. [2]

REFERENCES CONT. [3] Engelmann, C. R., Neis, J. P., Kirschbaum, C., Grote, G., & Ure, B. M. (2014). A Noise-Reduction Program in a Pediatric Operation Theatre Is Associated With Surgeon’s Benefits and a Reduced Rate of Complications: A Prospective Controlled Clinical Trial. Annals of Surgery, 259(5), 1025-1033.

[4] Murthy, V., Malhotra, S., Bala, I., & Raghunathan, M. (1995). Detrimental effects of noise on anaesthetists. Canadian Journal of Anaesthesia, 42(7), 608-611. [5] Broom, M., Capek, A., Carachi, P., Akeroyd, M., & Hilditch, G. (2011). Critical phase distractions in anaesthesia and the sterile cockpit concept. Anaesthesia, 66(3), 175-179.

LITERATURE STAFF SATISFACTION

Staff Performance

THERMAL CONDITIONS

• Satisfaction with indoor temperature was significantly higher in ORs with indoor environmental controls (IEC) vs. in

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STAFF PERFORMANCE

SIGNIFICANCE

Staff Safety

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• Surgeons were more stressed and perceived higher task workload, distractions and errors during hot conditions, compared to colder room temperature (19 and 26 C˚). [2]

Temperature is considered an important criterion for providing a comfortable indoor environment in the operating room. Evidence suggests that employing indoor environmental controls in the operating rooms results in higher satisfaction with indoor temperature. Comfortable thermal condition in the operating rooms were associated with staff satisfaction and work-related health symptoms; however, studies represent a diverse range of comfort temperature associated with different functions. For example, surgery patients may need a warmer temperature than is comfortable for gowned surgical staff. Thermal conditions in the OR can contribute to the staff’s performance, which is vital for patient safety and care.

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• LED surgical lights produce significantly less heat and may make the temperature of the immediate surgical

Staff Satisfaction

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environment easier to control.[3]

STAFF SAFETY

• Lack of humidity controls in the ORs resulted in dry skin, dry eyes, or dry throat in staff. [1]

REFERENCES [1] Dascalaki, E. G., et al. (2009). Indoor environmental quality in Hellenic hospital operating rooms. Energy and Buildings 41(5): 551-560. [2] Berg RJ, Inaba K, Sullivan M, Okoye O, Siboni S, Minneti M, Teixeira PG, Demetriades D. (2015). The impact of heat stress on operative performance and cognitive function during simulated laparoscopic operative tasks. Surgery 157, 87–95. [3] Maheshwari, K. (2012). Operating room design manual - chapter 9: Room ventilation systems. American Society of Anesthesiology.

LITERATURE STAFF PERFORMANCE & SATISFACTION

Staff Performance

LIGHTING

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• LED lighting was mainly preferred among general surgery and gynecology. [1] • Surgical lights attached to the boom are recommended for reaching the furthest point of the surgical bed and not

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interfere with monitor movements. [2]

SIGNIFICANCE

Staff Safety

Both general ambient lighting and focused surgical lights are required to not only deliver surgical care but also to minimize medical errors. In the operating room, proper lighting type and illumination quality is correlated with staff satisfaction and can impact patient safety outcomes. Illumination quality and the ergonomics of surgical lights can impact the surgeon’s performance. For example, from an ergonomic standpoint, older surgeons may need extra illuminance levels to reduce adverse events. As different surgeries require a different amount and quality of lighting, it is critical to provide flexible and easy-to-use lighting equipment for a variety of surgeries.

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• Using a single-use, flexible surgical light device reduced neck and back pain in surgeons. [3]

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Patient Safety

Efficiency

ERRORS

• Using a single-use, flexible surgical light device improved visualization for surgeons (Okoro et al., 2007) [3]

REFERENCES [1] Wauben, L., Van Veelen, M., Gossot, D., & Goossens, R. (2006). Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of 284 surgeons. Surgical Endoscopy And Other Interventional Techniques, 20(8), 1268-1274. [2] Hirsch, R. (2008). The hybrid cardiac catheterization laboratory for congenital heart disease: from conception to completion. Catheterization and Cardiovascular Interventions 71(3): 418-428.

Errors

[3] Okoro, S. A., Patel, T. H., & Wang, P. T. (2007). Who needs the surgical headlight? The Cleft Palate-craniofacial Journal, 44(2), 126-128.

LITERATURE STAFF PERFORMANCE & SATISFACTION

Staff Performance

VISIBILITY

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• Comfortable viewing distance ranged between 60-100 cm, with the vertical inclination of gaze direction between 0-16 degrees.[1]

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• Number of monitors depends on the type of surgery. Laparoscopic surgeries requires at least two monitors while

SIGNIFICANCE

ERRORS

Clear sightlines to the patient are critical at all times for all surgical team members. Further, visibility of other team members and views of key information displays is critical. Visibility of floor surfaces is also important to prevent tripping on wires and hazards. Assessing different sightlines should be an important aspect of testing different room sizes and layouts, to reduce surgical errors and fatigue

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• Hand-level display positioning of monitors showed fewer errors and shorter execution times, compared to eye-level

Staff Satisfaction

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additional monitors are required for radiology. [2]

Staff Safety

Errors

display. [3]

• The most comfortable position for the surgeon is locating the monitor diagonally that delivers the highest level of optical correctness and reduces interference with the surgeon’s line of sight. Additionally the scrub nurse and assistant had visual access to the image display. [4]

REFERENCES [1] Jaschinski W, Heuer H, and Kylian H. (1998). Preferred position of visual displays relative to the eyes: A field study of visual strain and individual differences. Ergonomics 4, 1034 –1049.

[3] Omar AM, Wade NJ, Brown SI, and Cuschieri A. (2005). Assessing the benefits of “gaze-down” display location in complex tasks. Surgical Endoscopy, 19, 105–108.

[2] Patkin, M. (2003). What surgeons want in operating rooms. Minimally Invasive Therapy & Allied Technologies, 12(6), 256-262. .

[4] Marcos, P., Seitz, T., Bubb, H., Wichert, A., & Feussner, H. (2006). Computer simulation for ergonomic improvements in laparoscopic surgery. Applied ergonomics, 37(3), 251-258.

emperical grey user literature literature insights

DESIGN CONSIDERATIONS □□

EQUIPMENT AND INSTRUMENTS

□□

Use of flexible and moveable equipment to meet hybrid teams and operation requirements. For example, placing table diagonally can provide more space and flexibility, and provide access to the patient from all sides □□ Accommodate different types of endoscopes and laparoscopes using Plug and Play design to account for expandability and flexibility □□ Connect surgical equipment on the same audio-visual management system for de-cluttering and increasing efficiency □□ Use of flexible high definition imaging screens fixed to ceiling booms with movable (on/off sterile field) mounted surgical lights □□ Provision of a flexible clutter free floor by using ceiling booms to hold all equipment

□□

□□ □□

MATERIALS

AUDITORY CONDITIONS

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Trade off between providing non-porous cleanable surfaces for cleanability and infection control and porous sound absorbing materials in the OR

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VENTILATION & AIR QUALITY

Use of air curtains or laminar flow in OR and to ventilate the sterile zone including material and instrument tables Use of a monolithic ceiling and full scale temperature and humidity controls

TOOLS & TECHNOLOGY

Incorporate integrated systems in the suites for easy access to data, storage and exchange of patient and surgery information using multiple modes such as internet, microphones and speakers □□ Provision of one or multiple access points to control all electronic equipment

emperical grey user literature literature insights

□□

THERMAL CONDITIONS

□□

LIGHTING

Provision of temperature and humidity controls that are accessible to staff

Provision of flexible, stable, and moveable light structures in the OR, with a centrally located light over the table Provision of ergonomic lighting that is easy to adjust and position that does not interfere with airflow and visibility of monitors

VISIBILITY

□□

A physical mock-up is critical for visualizing different locations of people, equipment and displays

Seamless floor and walls for the ease of cleaning Cleanable materials for walls, flooring as well as horizontal surfaces

03 FLOWS DEFINITION

Surgical flow, which includes the sequence and dynamic directions of activities of people and objects, is critical from the perspective of managing costs, efficiency, as well as quality of care in the surgical process. Understanding these flows is critical while designing surgical facilities. There are a range of essential and potential activities needed for successfully performing surgical procedures and providing patient care in a surgical services department. This section will focus on outlining these activities as key steps inherent to a set of surgical flow types. These activities could potentially take place in different types of spaces depending on the service model. However, the diagrams presented in this section do not imply specific types of spaces or represent physical distances between spaces. These aspects will be explored in a further section focused on case studies, where the key steps outlined in this section are shown on the plan of the surgical services department to highlight how different facilities have addressed these flows.

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The sequences of steps for the different flows that are part of the surgical process were abstracted from empirical studies* and from the surgery observations conducted by the RIPCHD.OR research team. Surgical flows were then differentiated as patient flow, family flow, staff flow, instruments/materials/supplies flow, and equipment flow. Their graphic representations are displayed in the following pages, in the form of flo diagrams, where circles represent steps (not spaces), and arrows represent the direction of the flow. * Smith et al, 2008; Fredendall et al, 2009; Schwarz et al, 2010; and Brown et al, 2014.

GOAL & PURPOSE

Understanding and clearly defining the different process flows is an integral part of the RIPCHD.OR learning lab. The purpose of this exercise was to understand the basic flows for different people and objects so that the potential variations to these basic flows brought about as a result of physical design, technology or process interventions can be understood. While the activities represented in each step can be performed together or separately, in one or multiple spaces, design choices impact both ‘where’ activities are performed and ‘how’ they are performed. For example, the transportation of patients and items supporting surgeries (i.e. sterile instruments), may take place differently depending on how steps are spatially organized, ultimately shaping the efficiency the process.

PATIENT & FAMILY FLOW PATIENT The ambulatory surgery process for the patient typically involves key activities performed preoperatively to get ready for surgery, the surgery itself followed by recovery from anesthesia and discharge. Steps such as waiting, may or may not happen depending on how spaces are organized and on patient scheduling and coordination at the facility. Thus, these steps are considered as optional (potential steps) in the flow.

1A WAITING ARRIVAL

ADMISSION

PRE-OP ASSESSMENT

FAMILY

INDUCTION

The participation of family members varies across the surgical process, also depending on surgery types. Parents usually undertake more steps following the patient in pediatric procedures, while family members may also participate in preop assessment and anesthesia induction when these steps are parallel to the surgical procedure (see induction rooms in the Case Study section). Essential step Flow through process Potential step

ARRIVAL

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ADMISSION

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PRE-OP ASSESSMENT

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COMPLICATIONS?

HOSPITAL

6A STEP DOWN RECOVERY

SURGERY

EMERGENCE

POST ANESTHESIA RECOVERY

DISCHARGE

COMPLICATIONS?

PICK UP

HOSPITAL

4A STEP DOWN RECOVERY

INDUCTION

WAITING

REPORT FROM SURGEON

POST ANESTHESIA RECOVERY

DISCHARGE

PICK UP

Potential flow through process

STAFF FLOW SURGEONS The surgical team varies in its composition, and includes attending surgeons, residents, and at times medical students. While they share fixed activities around the surgery itself, attending surgeons are usually responsible for reporting to family members on the progress of the surgery (dictating and talking to the patientâ&#x20AC;&#x2122;s family).

1A ARRIVAL

CHECKING PATIENT (PRE-OP)

(RESIDENT)

TIME-OUT

CHANGING CLOTHES

ANESTHESIOLOGISTS The anesthesiology team, including anesthesiologists and nurse anesthetists, is also involved at multiple points across the surgical process,. Their flow follows parallel to the patient flow.

ARRIVAL

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Essential step Flow through process Potential step

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SCRUBBING

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PERFORMING SURGERY

DICTATING

REPORTING TO FAMILY

CHECKING PATIENT (POST-OP)

(ATTENDING)

(RESIDENT)

ANESTHESIA INDUCTION

TIME OUT

SUPPORTING SURGERY MONITORING PATIENT/ MANAGING MEDICATION

ANESTHESIA EMERGENCE

HANDING OFF INFORMATION (POST-OP)

Potential flow through process

INSTRUMENTS & MATERIALS FLOW STERILE INSTRUMENTS & MATERIALS The flow of sterile instruments and materials is influenced by the system of sterilization used: imbedded in the facility (like a Central Sterilization Processing unit) or outsourced. The latter appears in the flow diagram as a set of potential steps, like receiving and distributing items after their arrival or before their send-off. Additionally, this type of flow has to consider not only items that have to be reprocessed, but also items that become waste (i.e. disposable packages) and are directed to a waste management process.

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RECEIVING/ DISTRIBUTION

PREPARING FOR STERILIZATION (CLEAN)

STERILE PROCESSING

STAGING (STERILE)

STORAGE & DISTRIBUTION (STERILE)

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Essential step Flow through process Potential step

ARRIVAL

OUTSOURCED STERILIZATION PROCESSING

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DISASSEMBLY (STERILE)

UNPACKAGING + INVENTORY (STERILE)

STAGING (STERILE)

SURGERY

ASSEMBLY (SOILED)

CLEANING + INVENTORY (SOILED)

CENTRAL WASTE STORAGE (SOILED)

TEMPORARY WASTE STORAGE (SIOILED)

WASTE DISPOSAL (SOILED)

Potential flow through process

SUPPLIES FLOW

EQUIPMENT FLOW

Supplies include anesthesia medication and disposable items, which are respectively consumed by the patient during surgery or discarded as waste. These items may be stored different (facility storage and OR storage), and have different flow directions after surgery. They are either being consumed by the patient, returning to storage if not used or being directed to waste management (i.e. disposable packages).

FACILITY STORAGE

OR STORAGE + INVENTORY

STAGING

SURGERY

CENTRAL WASTE STORAGE

TEMPORARY WASTE STORAGE

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Essential step Flow through process Potential step

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MOVABLE EQUIPMENT

SUPPLIES

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WASTE DISPOSAL

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The flow of equipment in surgical facilities is influenced by where equipment is stored, cleaned and prepared for surgical procedures. Storage steps depend on facility policy regarding storage of different types of equipment and may result in equipment being stored at the facility level storage or surgical procedure level storage (OR storage). Transportation then depends on the decisions made the location of storage , always depicted as a potential step in the flow stream.

1A OR STORAGE

FACILITY STORAGE

CLEANING

STAGING

SURGERY

NOTE For the staff flow, surgeons and anesthesiologists were identified as the most representative groups of professionals, since they are active participants across the surgical process (before, during and after surgeries). Other staff members like scrub and circulating nurses, although considered in the larger scheme of this research, and extremely important in the surgical process, were not included in this book due to their primary focus on activities usually being limited to the operation room (during surgery). There was also a simplification in the number of categories used to depict the flow of items supporting the surgical process. Although there are many other types of items being considered in the scope of this research (i.e. fluids, linen, surgical drapes), only two groups of items (sterile instruments/materials and supplies) were sufficiently expressive and consistent across the process to be translated into flow streams, also having a bigger impact in the physical configuration of surgical facilities. The criteria to differentiate between these two flows was whether or not they were reprocessed (instruments and materials) or consumed by the patient during surgery (supplies), which is usually in the form of anesthesia medication.

Potential flow through process

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g n i t s 04 CASE STUDIESe T & DEFINITION gn i s e D ies

As outlined in the AHRQ grant, video footage was taken of actual outpatient surgeries at the Medical University of South Carolina hospital system. From this footage a cross-section of surgeries were observed in the making of the following procedure maps. These maps attempt to define the realities of the different phases during various operations. The phases include patient preparation, intraoperative and postoperative. Patient preparation begins once a patient has entered the threshold of the operating room. The intraoperative phase begins once a patient has been anesthetized. Finally, the postoperative phase begins when the anesthesiologists conclude the induction. Postoperation concludes once the patient has left the operating room. The following procedure maps do not include the turn-around activity required at the start and conclusion of each surgery. During turn-around the room is sanitized and straightened by environmental services staff members. Within the three phases the surgical team, patient, movable furniture and required equipment are diagrammed relative to the surgical table. The following sequence of diagrams includes: similarities across the procedure maps, individual diagrams of the surgeries, and differences across the procedure maps.

GOAL & PURPOSE The primary goal of these procedure maps is to document the nature and configuration of events and activities. Through this documentation tool of diagrams the reader should be able to further understand and learn the various actions occurring in the operating room. Ultimately these diagrams can be used to inform and visually test various design configurations.

SPARTANBURG REGIONAL HEALTHCARE SYSTEM

g n ti s Te Characteristics

SQF 2,34,000

OWNER/AFFILIATION Spartanburg Regional Health System

ARCHITECT(S) McMillan Smith & Partners Architects, PLLC

TYPE OF FACILITY Emergency services

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Spartanburg, South Carolina

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- eighteen operating rooms around a clean core - Clear and efficient floor plan with dedicated preop, operating rooms and postop, with their respective central staff working areas

- Clear separation between restricted red line areas and areas for the general patient population. - The stainless steel wall constructions allow for flexibility for the future. - Clear separation between staff spaces, administrative spaces and patient spaces. - Clear separation between material,staff and patient flows.

About this Clinic from McMillan Smith & Partners :

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Spartanburg Regional Healthcare System is an integrated healthcare delivery system that provides care from one’s birth through the senior years. The hospital’s planning staff and the firm’s Healthcare Studio consulted with UPS to understand the shipper’s tracking technology and methods for integrating contingency plans into standard operating procedures. The Design Team’s due diligence and thorough research led to a new 234,000SF facility, including a 55,000SF new Level 1 Trauma Center that combines advanced patient care techniques with a customer service focus for the second busiest emergency department in the Carolinas.

pre-op post-op admin staff support/work area OR

NORTH Diagram Adapted From Spartanburg Regional Medical Center by Rutali Joshi

SPARTANBURG REGIONAL HEALTHCARE SYSTEM FLOWS & TYPES PATIENT 1. Admission a. Waiting 2. Pre-Op Assessment 3. Induction 4. Surgery 5. Emergence 6. Post Anesthesia Recovery a. Step-down Recovery 7. Discharge

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SURGEON 1. Change Clothes 2. Pre-Op Assessment 3. Check other patients 4. Scrub 5. Time-Out 6. Surgery 7. Dictating 8. Report to Family 9. Post Anesthesia 10. Check other patients

6a-7

3-5

2 1A 2

3-5

4-5

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5-7 3-6

1. Admission a. Pre-Op Assessment 2. Waiting 3. Report from Surgeon 4. Post Anesthesia Recovery 5. Discharge

Change Clothes Pre-Op Assessment Anesthesia Induction Time-Out Monitoring during surgery Anesthesia Emergence Post Anesthesia hand-off

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FAMILY

1. 2. 3. 4. 5. 6. 7.

Patient Family Surgeon Anesthesiologist Diagram Adapted From Spartanburg Regional Medical Center NORTH by Rutali Joshi

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SUPPLIES/MEDICATION/DISPOSABLES

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1. 2. 3. 4. 5. 6. 7.

STERILE INSTRUMENTS/MATERIALS

1-2

1. Sterile Processing 2. Clean Staging 3. Storage and Distribution 4. Disassembly 5. Unpackaging & Inventory 6. Assembly 7. Surgery 8. Reassembly/Inventory/Cleaning 9. Cart Reassembly 10. Soiled Staging

2-3

2 3-5 6-9

3-5

MOVABLE EQUIPMENT

6 4

1. 2. 3. 4.

5-7

2-3

5-7

Storage/Pharmacy Storage & Inventory Staging for Surgery Surgery Waste Temporary Waste Storage Central Waste Storage

Central Storage Department Storage Cleaning Staging for Surgery Supplies/Medications/Disposables Sterile Instruments/Materials Movable Furniture or Equipmen

5-7

NORTH

Diagram Adapted From Spartanburg Regional Medical Center by Rutali Joshi

LESSONS LEARNED

Modularity increases flexibility

Recessed storage maximizes valuable floor space

Greater area in the OR increases flexibility

Walls covered with modular panels facilitate ease of maintenance and increase flexibility for future reconfiguration of ORs, as the individual panels can be temporarily removed for maintenance or easily replaced. In addition to reducing maintenance time and costs, this system provides stainless steel panels to protect walls from potential bumping of movable equipment and furniture in high traffic areas. In the OR and other sterile areas the stainless steel is coated with color, while the dirty areas are lined with stainless steel to assist wayfinding within the OR suite.

Storage cabinets that are recessed into the wall of the OR provide ample storage for surgical supplies, while reducing clutter around the perimeter of the room.

Larger sized ORs afford the inclusion of moveable diagnostic and robotic equipment within the operating theatre without impeding flow outside the sterile zone. The increase in area also supports greater flexibility for the varying positions of bed and equipment for multiple procedures.

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Strategic integration of technology increases efficiency

Connectivity increases staff safety

Adjacencies are critical to flow optimization

Technology such as the Neptune, a selfcleaning blood containment machine, and a wand that detects surgical supplies that could be potentially left inside the patient increase staff and patient safety by reducing exposure to infectious material and potential surgical site infections, while also providing efficiency with waste removal and surgical closing. Inside the operating room, lack of direct visibility from the circulating nurseâ&#x20AC;&#x2122;s workstation to procedure area is compensated by a video of the procedure displayed on the nurseâ&#x20AC;&#x2122;s monitor.

Layering electrical outlets at varying heights through the use of surgical booms and multiple locations throughout the OR reduces the amount of electrical wires on the floor, decreasing tripping hazards for staff.

The patient/family waiting room and sterile processing area are located on different floors than the OR, requiring longer travel distances and extended travel time due to the use of elevators to move patients, staff and supplies through the system. Close proximity between the preoperative and postoperative areas affords flexibility in staffing and accommodates flexing between the two areas during peak volumes throughout the day.

LOCKERS 1-914

ELEC 1-915

CT136.10N

TLT 1-308

CU 1-407

ECHO (URGENT CARE EXAM) 1-405

SU 1-306

EXAM 1-309

RIPPLE

A3615.1636

E2110.2448L

A3615.1636

EXAM 1-409

EXAM 1-403

NURSE WORK 1-400

38/30E

FEC-2

LASER 1-202

ENT EXAM 1-213

E2110.2472L

CONSULT 1-313

CAST/EXAM 1-503

EXAM 1-410

EXAM B 1-402

ENT EXAM (NEG) 1-214

EXAM (NEG) 1-401

E3212.36F

AO610.1636

E2110.2472L

G6120.36DS

THERAPY 1-201

TLT 1-112

CORRIDOR 1-C-62

CORRIDOR 1-C-60

CAST/EXAM 1-511

NURSE WORK 1-500

RIPPLE

E2841.33

CO212FF

46/48G

46/24N

E1109.4624N

PARENT SLEEP 1-113

INF TLT 1-101B

TLT 1-508

CAST/EXAM 1-510

CO212FF

E1109.4648G

CO212FF

46/48G

38/30E

E1109.3830E

E2110.2460L

CAST/EXAM 1-512

CAST/EXAM 1-502

CAST/EXAM 1-513

CAST/EXAM 1-501

EXAM (NEG) 1-411

VISUAL FIELD 1-111

E3212.36F

CORRIDOR 1-C-03

CORRIDOR 1-C-01

FEC-2

E1422.1642

FEC-2

RECEPTION / CHECK OUT 1-011

A3615.1636

E2110.2448L E2110.2448L

70WSN E1224.

GEN RADIOLOGY 1-505

SU 1-506

RAD CONTROL 1-505A

CU 1-507

TLT 1-508

STORAGE 1-001B

EXAM 1-309

TLT 1-205

2 A3.09

ELEV LOBBY 1-010

733-66M

EEG/PFT 1-304

FT210.2454L

FT210.2424L

FT210.2454L

E2844.30

38/30E

CO212FF

46/48G

TLT 1-408 CORRIDOR 1-C-62

CAST/EXAM 1-510

CO212FF

E1109.4648G

CO212FF

46/48G

CO212FF

38/30E

EXAM 1-404

E1109.4648G

EXAM 1-310

TEAM CIRCULATION 1-300B

CO212FF

ELEV E2

E2110.2448L

ELEV E1

3 A3.08

CO212FF

ENTRY VESTIBULE 1-009

NURSE WORK 1-300 WC STOR 1-010A

46/24N E1109.4624N

CO212FF

EXAM 1-204

CORRIDOR 1-C-52

46/24N E1109.4624N

E2110.2448L

38/30E

E2841.33

CORRIDOR 1-C-54

CONSULT 1-504

CORRIDOR 1-C-58 STAIRS S1-1

E3212.36F

ENT EXAM 1-211

OPTHALM 1-107

CAST/EXAM 1-509

3 A3.10

RIPPLE

E2110.2436L

38/30E

Y2091.

E1109.3830E

FT210.2448L

38/30E

ALCOVE 1-C-93A

WC SCALE 1-C-93B FEC-2

CU 1-407

GREETER 1-011A TOILET 1-210

E2110.2448L

E1109.3830E

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SPORTS MEDICINE 1-001

CAFE 1-003

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ECHO (URGENT CARE EXAM) 1-405

SU 1-306

GT32 ACW32

E1109.3824E

SPORTS MED CHANGING 1-001A

40" BARIATRIC

LOUNGE 1-920

STORAGE 1-919

STAFF TLT 1-918

ICE

CO561FL

E1422.1630

EVS REF 1-917

E2110.2448L

A3615.1636

TA16 TA16

Workroom 1-002

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E2110.2478L

E1109.3830E

TLT 1-308 CU 1-307

STORAGE 1-305

E1411.3224T E1446.3224

38/30E

70/24N

E1109.7024N

CORRIDOR 1-C-93

TA G : E 0 20

GRINDMASTER BUNN RACK 890-TS DIGITAL BREWER TA G : E 1 74 208V TA G : E 5 33 SCALE

ALCOVE 1-C-93C

WC SCALE 1-C-91A

CELL 01 PHARMACY / STORAGE PHLEBOTOMY 1-209 PAUSE 1-014

CU 1-208

SU 1-207 ACW32 GT32

E1109.3830E

HAND SINK

FEC-2

E2110.2478L E1109.7048G E1411.3248T E1446.3248

E1411.3248T E1446.3248

Y2091.

PAUSE 1-004

FT210.2442L FT210.2448L

ACW32 GT32

GT32 ACW32 70/48G

Y2091.

E1109.3824E

TRASH/LINEN HOLD 1-916

E2110.2472L

FT210.2442L

AUDIOLOGY BOOTH 1-018G

E1109.7042G E1411.3242T E1446.3242

AUDIOLOGY BOOTH 1-018E

3 A3.05

46/24N

E1109.4624N

3 A3.12

OPTHALM 1-108

38/30E

E1109.3830E

E2841.33

ELEV E3

MEN'S TLT 1-005

E1411.3242T E1446.3242

ACW32 GT32

EXAM 1-206

OPHTHALM SUBWAIT 1-106

FT210.2460L

GT32 ACW3270/42G

CT136.10N

E2110.2448L

STAIRS S3-1 ELEC 1-915

OVEN E1109.3824C

CT136.10N

AUDIOLOGY WORK 1-018A

E2110.2472L

FEC-2

LOCKERS 1-914

OFFICE 1-913

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PHARMACY 1-016

FT210.2472L

INF TLT 1-101F

E2110.2472L

FEC-2

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MGR OFC 1-912

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FAM TLT 1-007

E2110.2460L

E2110.2472L

WOMEN'S TLT 1-006

E2110.2442L

COPY/WORK 1-012

HOBART

E2110.2448L

E2110.2442L

SECURITY DATA/ TELECOM 1-910

AO610.1636

CT136.10N

PHLEB WORK 1-015D

PHLEBOTOMY DRAW 1-015A

E2110.2478L

AUDIOLOGY BOOTH 1-018F

E2110.2448L

AO610.1636

AUDIOLOGY BOOTH 1-018D

E2110.2448L

A3615.1636 AO610.1636

G6120.36DS

C3010.1336

E2110.2442L

SECURITY INTERVIEW 1-013

SPEC TLT 1-105C

PHLEBOTOMY LOUNGE 1-015 1-909

COORD/PROG ASST OFC 1-908

IV PREP ANTEROOM 1-016B

G6120.36DS

SLEEP MGR OFC 1-907

AO610.1636

ELEC 1-906

CT136.10N

C3010.1336

G6120.36DS

E2110.2448L

AO610.1636

STAFF TLT 1-905

C3010.1336

CU - CELL 01 1-904

MED REC 1-903

A3615.1636

TEAMING ROOM 1-902

A3615.1636 C3010.1336

G6120.36DS

AO610.1636

E2110.2472L

G6120.36DS

R16

PHLEBOTOMY DRAW 1-015B

E2110.2466L

AUDIOLOGY 1-018 A3615.1636 AO610.1636 G6120.36DS

G6120.36DS

C3010.1336

A3615.1636

E2110.2472L

BAER RM E2110.2448L 1-018C

IV PREP 1-016C

VESTIBULE 1-016A

EVS 1-017

AO610.1636

E2110.2466L

G6120.36DS

E2110.2472L

WORKROOM 1-901

E2110.2472L

A3615.1636

G6120.36DS

E2110.2466L

HALLWAY A3615.1636 AO610.1636 1-C-01A

A3615.1636

E2110.2472L

COMMUNITY EDUCATION 1-019

COAT MOP RACK SINK

E3230.42

E3230.36

ELEC 1-020

A3615.1636

E2110.2436L

E3230.42

ELIASON WRKROOM 36"

ALCOVE 1-C-01B

E3230.30 G6120.30NS

EXAM 1-203

CORRIDOR 1-C-60

CORRIDOR 1-C-56

ENT EXAM 1-212

EXAM 1-409

EXAM 1-403

NURSE WORK 1-200

38/30E

E1109.3830E

E2110.2460L

CAST/EXAM 1-503

CAST/EXAM 1-511

NURSE WORK 1-500

NURSE WORK 1-400

OPTHALM 1-109

38/30E

pre-op medical pod post-op admin staff support/work area or imaging

RIPPLE

FEC-2

LASER 1-202 ENT EXAM 1-213

EXAM 1-410

EXAM B 1-402

CAST/EXAM 1-512

CAST/EXAM 1-502

TELLER ACUITY 1-110 PARENT SLEEP 1-113

THERAPY 1-201

ENT EXAM (NEG) 1-214

CONSULT 1-313

E2110.2472L

TLT 1-112

EXAM (NEG) 1-401

E3212.36F

AO610.1636

E2110.2472L

G6120.36DS

INF TLT 1-101B

CAST/EXAM 1-513

CAST/EXAM 1-501

EXAM (NEG) 1-411

VISUAL FIELD 1-111 E3212.36F

CORRIDOR 1-C-03

CORRIDOR 1-C-01

FEC-2

FEC-2 E3230.42

E2110.2478L

TA16

70WSN

E2110.2448L E2110.2448L

E2110.2436L

Y2091.

38/30E

L Y2091.

FT210.2448L

E1109.3830E

STORAGE 1-001B

GREETER 1-011A

E2110.2448L

38/30E

FEC-2

E1411.3224T E1446.3224

E1109.3830E

E1411.3224T E1446.3224

FT210.2454L

FT210.2424L

E1109.3824E

CAFE 1-003

E1224.

E1422.1630

TA16

ICE

E1109.7024N

GT32 ACW32

E1109.3830E

ACW32 GT32

E1422.1642

FEC-2 E2110.2448L E2110.2448L

E2110.2478L FT210.2448L

E1109.7048G E1411.3248T E1446.3248

E1411.3248T E1446.3248

ACW32 GT32

38/30E

SPORTS MEDICINE 1-001

TA G : E 0 20

GRINDMASTER BUNN RACK 890-TS DIGITAL BREWER TA G : E 1 74 208V TA G : E 5 33 SCALE

PHARMACY / PHLEBOTOMY PAUSE 1-014

GT32 ACW32 70/48G

E1109.3830E

REF UP

PAUSE 1-004

FT210.2442L FT210.2442L

E1109.7042G E1411.3242T E1446.3242

Y2091.

E2110.2466L

SPORTS MED CHANGING 1-001A

40" BARIATRIC

HOBART Workroom 1-002

E1411.3242T E1446.3242

ACW32 GT32

Y2091.

E1109.3824E

E2110.2448L

STAIRS S3-1

HAND SINK

MEN'S TLT 1-005

GT32 ACW3270/42G

FT210.2460L

70/24N

E2110.2472L

FEC-2

OVEN E1109.3824C

AUDIOLOGY BOOTH 1-018G

FAM TLT 1-007

RECEPTION / CHECK OUT 1-011

2 A9.35

FT210.2472L

AUDIOLOGY BOOTH 1-018E

WOMEN'S TLT 1-006

E2110.2442L

E2110.2478L

PHLEB WORK 1-015D

PHLEBOTOMY DRAW 1-015A

PHARMACY 1-016

COAT MOP RACK SINK

E3230.42

COPY/WORK 1-012

PHLEBOTOMY 1-015

IV PREP ANTEROOM 1-016B

E3230.36 E3230.36 A3615.1636 AO610.1636 G6120.36DS

AUDIOLOGY WORK 1-018A

E2110.2442L

E3230.36

HEARING AID 1-018B

E2110.2448L

AUDIOLOGY BOOTH 1-018F

E2110.2448L

AUDIOLOGY BOOTH 1-018D

E2110.2448L

FT210.2448L

SECURITY INTERVIEW 1-013

SPEC TLT 1-105C

AUDIOLOGY 1-018

E2110.2448L

E3230.48

PHLEBOTOMY DRAW 1-015B

IV PREP 1-016C

VESTIBULE 1-016A

EVS 1-017 BAER RM 1-018C

COMMUNITY EDUCATION 1-019

ELIASON WRKROOM 36"

ALCOVE 1-C-01B

HALLWAY 1-C-01A

ELEC 1-020

E3230.30 G6120.30NS

FT210.2454L

3 A3.05

2 A3.09

ELEV LOBBY 1-010

3 A3.10

STAIRS S1-1

ENTRY VESTIBULE 1-009 WC STOR 1-010A

ELEV E1

3 A3.08

ELEV E2

3 A3.12

40" BARIATRIC

SECOND FLOOR SUPERVISOR OFC 2-909

STAIRS S2-2

TRASH/LINEN HOLD 2-912

ASC LOCKER RM (FEMALE) 2-910

ASC LOCKER RM (MALE) 2-913

ELEC 2-911

IDF 2-908 DATA/ TELECOM 2-907

40" BARIATRIC

LOCKER ROOM (MALE) 2-906

LOCKER ROOM (FEMALE) 2-905

ELEC 2-904

E1422.1630

ADMINISTRATIVE WORK 2-902

STORAGE 2-914

LOUNGE ADMIN 2-903

DIRECTOR'S OFC 2-901

TA16

LOUNGE-ASC 2-915

CORRIDOR 2-C-91

CORRIDOR 2-C-93

CORRIDOR 2-C-92

COPIER

ADMIN STORAGE 2-209

ADMIN WORK 2-208

CORRIDOR 2-C-74B

MRI EQUIP 2-212

MECH. SHAFT #1 xxx

ALCOVE 2-C-93A

CO212FF

NEMSCHOFF PRT T-12

CLEAN WORK 2-211

SU - IMAGING 2-210

RAD READING 2-201B

NEMSCHOFF PRT T-12

F 2 N EMSCHOF PRTT-1

STORAGE 2-301G

RECOVERY A 2-300D

MRI RECOVERY 2-300C

NEMSCHOFF PRT T-12

RECOVERY A 2-303C

EQUIP 2-308

RECOVERY B 2-303E MECH. SHAFT #4 XXX

RECOVERY A 2-303D

CU - RECOVERY 2-301A

CENTRAL STERILE 2-307

CO212FF

RECOVERY B 2-300E

CO212FF

ALCOVE 2-201A

ALCOVE 2-301F

MRI 2-200B

SUPERVISOR OFC 2-201D

TLT 2-303F

E1422.1648

TA16

PACU CORRIDOR 2-301

IMAGING 2-201

BLA NKET WA RMER

CONFERENCE 2-207 TA16

CORRIDOR 2-C-76

SHELLED (MRI/CT) 2-213 CORRIDOR 2-C-72

NOURISH 2-301E

RAD CONTROL 2-201C

RECOVERY A 2-303G

PT TLT 2-301B

CORRIDOR 2-C-74A

ULTRASOUND 2-203

NE MSCHOFF PRTT-12

RECOVERY A 2-300F

TAG2

TAG1

CATLG

DESC2

DESC1

STYLE

REFTAG

TAG2

TAG1

CATLG

DESC2

DESC1

DECONTAM 2-306

6'-10" NEMSCHOFF PRTT-12

TAG2

TAG1

CATLG

DESC2

DESC1

6'-10"

STYLE

PACU TEAMING 2-303

E1422.1642

TA16

REFTAG

RECOVERY A 2-303H

E1422.1636

TA16

NE MSCHOFF PRTT-12

NEMSCHOFF PRTT-12

MSCHOFF PRTT-12

7'-0"

TAG2

TAG1

CATLG

DESC2

DESC1

STYLE

REFTAG

TA16

RECOVERY A 2-303B

STAFF TLT 2-301D

GOWNING 2-301C E1422.1636

7'-0"

NEMSCHOFF PRTT-12

PACU TEAMING 2-300

MRI VESTIBULE 2-200

SHELLED (ULTRASOUND) 2-202

NE MSCHOFF PRTT-12

GEN RADIOLOGY 2-204

REFTAG

RAD EQUIP 2-204A

NEMSCHOFF PRTT-12

RECOVERY A 2-300B RAD FLUOROSCOPY 2-206

MRI CONTROL 2-200A

4'-6"

RECOVERY C 2-300A

RF TLT 2-205

ASC CONTROL 2-302

RECOVERY A 2-300G

RECOVERY A 2-303A

EVS-ASC 2-304

4'-6"

CORRIDOR 2-C-53

ALCV. 2-401C

ASC CONSULT 2-005 EVS 2-109

SU-ASC 2-305

CART ALCOVE 2-C-53A

CODE CART

CORRIDOR 2-C-51

SCRUB 2-401B

SCRUB 2-403B

ALCV. 2-404C

ALCV. 2-406C

SCRUB 2-404B

SCRUB 2-406B

ANES. ALCOVE 2-C-36B

TLT 2-010

SHELLED (LAB) 2-110 SUBWAIT 2-111

MRI INDUCTION 2-007

STORAGE 2-402

TLT 2-009

STORAGE 2-405

FEC-2

FRZ R

40" BARIATRIC

STAFF TLT 2-108

TLT 2-111C

IV START 2-006

STORAGE 2-408 SHELLED OR 2-406

DRESSING 2-111A

MECH. SHAFT #2 XXX

ASC CONSULT 2-004

TLT 2-101A

GTTLRTC92PS

OR (GENERAL) 2-403

OR (GENERAL) 2-401

OR (GENERAL) 2-404

Y7520.AQWM

CORRIDOR 2-C-36

Y7520.AQWM

VITROS ANALYZER

DRESSING 2-111B

40" BARIATRIC O

PREP\ INDUCTION A 2-417

MRI EQUIP 2-212

MECH. SHAFT #1 xxx

MICROSCOPE

PREP/ INDUCTION B 2-419

CLEAN WORK 2-211

TLT 2-413

NEMSCHOFF PRT T-12

F 2 N EMSCHOF PRTT-1

STORAGE 2-301G

RECOVERY A 2-300D

CU - RECOVERY 2-301A

CO212FF

FIRST FLOOR RAD CONTROL 2-201C

4 A3.08

ELEV E1

E1422.1648

TA16

3 A3.11

TA16

NOURISH 2-301E

ELEV E2

RECOVERY A 2-303G

PT TLT 2-301B

CORRIDOR 2-C-74A

ULTRASOUND 2-203

NE MSCHOFF PRTT-12

RECOVERY A 2-300F

TAG2

TAG1

CATLG

DESC2

DESC1

STYLE

REFTAG

TAG2

TAG1

CATLG

DESC2

DECONTAM 2-306

6'-10" NEMSCHOFF PRTT-12

TAG2

TAG1

CATLG

DESC2

6'-10"

DESC1

PACU TEAMING 2-303

E1422.1642

TA16

STYLE

TA16

RECOVERY A 2-303B

STAFF TLT 2-301D

GOWNING 2-301C E1422.1636

REFTAG

7'-0"

RECOVERY A 2-303H

TA16

NE MSCHOFF PRTT-12

NEMSCHOFF PRTT-12

MSCHOFF PRTT-12

TAG2

TAG1

CATLG

DESC2

DESC1

STYLE

7'-0"

NEMSCHOFF PRTT-12

PACU TEAMING 2-300

MRI VESTIBULE 2-200

NEMSCHOFF PRTT-12

RECOVERY A 2-300B GEN RADIOLOGY 2-204 SHELLED (ULTRASOUND) 2-202

http://www.nbbj.com/work/seattle-childrens-hospital-bellevue-clinic-and-surgery-center/

CENTRAL STERILE 2-307

TLT 2-303F

CORRIDOR 2-C-76

REFTAG

RAD EQUIP 2-204A

MECH. SHAFT #4 XXX

4 A3.10

NE MSCHOFF PRTT-12

RAD FLUOROSCOPY 2-206

EQUIP 2-308

RECOVERY B 2-303E RECOVERY A 2-303D

ALCOVE 2-301F

PACU CORRIDOR 2-301

SHELLED (MRI/CT) 2-213

REFTAG

CORRIDOR 2-C-72

NEMSCHOFF PRT T-12

RECOVERY A 2-303C

CORRIDOR 2-C-03

RIPPLE

3 A3.09

ELEV LOBBY 2-001 2 3 D-RFI A9.5061

STAIRS S1-2

NEMSCHOFF PRT T-12

CO212FF

RECOVERY B 2-300E

MRI 2-200B 4 A3.07

IMAGING 2-201

Diagram Adapted From NBBJ by Jessica Welch

ALCOVE 2-C-93A NEMSCHOFF PRT T-12

MRI RECOVERY 2-300C

ALCOVE 2-201A

RIPPLE

4 A3.06

BLA NKET WA RMER

CLEAN UTILITY 2-410

HALLWAY 2-C-03A

CO212FF

RAD READING 2-201B

CORRIDOR 2-C-01

RIPPLE

4 A3.05

TA16

STAIR S3-2

LOUNGE-ASC 2-915

CORRIDOR 2-C-93

E1422.1636

SU - IMAGING 2-210

SUPERVISOR OFC 2-201D

RIPPLE

STORAGE 2-914

PREP/ INDUCTION B (SHELLED) 2-414

PREP/ INDUCTION A 2-415 PREP/ INDUCTION B 2-416

PRE-OP TEAMING 2-418

NEMSCHOFF PRT T-12

CONFERENCE 2-207

ASC LOCKER RM (MALE) 2-913

CORRIDOR 2-C-74B

GLR92ES1S

REF

TRASH/LINEN HOLD MECH. SHAFT 2-912 #3 XXX

ELEC 2-911

PREP/ INDUCTION A 2-420

RA PID TESTING

ADMIN STORAGE 2-209

ASC LOCKER RM (FEMALE) 2-910

CORRIDOR 2-C-92

LAB OFC 2-103

COPIER

STRETCHER ALCOVE 2-C-36A

SUPERVISOR OFC 2-909

STAIRS S2-2

RECEPTION/ CHECK-OUT 2-002

PLAY 2-101

GLR92ES1C

MICROSCOPE

ADMIN WORK 2-208

WORK/COPY IDF 2-002A 2-908 DATA/ TELECOM 2-907

HOME CARE/DME 2-102

LOCKER ROOM (MALE) 2-906

CORRIDOR 2-C-91

FLA MMABLE STORAGE

SECURITY MONITORING 2-105

ASC/IMAGING PAUSE 2-008

LOCKER ROOM (FEMALE) 2-905

40" BARIATRIC

ELEC 2-904

E1422.1630

ADMINISTRATIVE WORK 2-902

STAFF TLT 2-106

CORRIDOR 2-C-34

LOUNGE ADMIN 2-903

SYSMEX

LAB 2-104

CORRIDOR 2-C-32

DIRECTOR'S OFC 2-901

MRI CONTROL 2-200A

4'-6"

RECOVERY C 2-300A

RF TLT 2-205

ASC CONTROL 2-302

RECOVERY A 2-300G

RECOVERY A 2-303A

EVS-ASC 2-304

4'-6"

SU-ASC 2-305

CART ALCOVE 2-C-53A

CODE CART

CORRIDOR 2-C-51

CORRIDOR 2-C-53

ASC CONSULT 2-005 EVS 2-109

ALCV. 2-401C

SCRUB 2-401B

SCRUB 2-403B

ALCV. 2-404C

ALCV. 2-406C

SCRUB 2-404B

SCRUB 2-406B

ANES. ALCOVE 2-C-36B

TLT 2-010

SHELLED (LAB) 2-110 SUBWAIT 2-111

MRI INDUCTION 2-007

STORAGE 2-402

TLT 2-009

FEC-2

STORAGE 2-405

FRZ R

TLT 2-111C

40" BARIATRIC

STAFF TLT 2-108

NORTH

ALCOVE 2-C-32A

ELEC 2-107

PACS 2-003

TA16

n e C

E1109.4648G

38/30E

E1109.3830E

r e t

H r fo

CO212FF

38/30E

lt a e

ENT EXAM 1-212

ALCOVE 1-C-93A

CU 1-507

TLT 1-408

46/24N E1109.4624N

OPTHALM 1-109

About this Clinic from the NBBJ website:

F h

46/24N E1109.4624N

CO212FF

EXAM 1-404

TELLER ACUITY 1-110

Bellevue, Washington

The architect focused on the use of Continuous Performance Improvement (CPI) and Integrated Project Delivery (IPD) to increase the efficiency of building the spaces. The focus on these processes allowed the architects to decrease building time, square footage and project cost to meet their goal of high quality care as cost effective care. The architects also spent a good deal of time studying the experience of bringing a child in for surgery. The design and layout of spaces is meant to allow parents to remain with their children for as long as possible and use daylight and calming views to dampen as much of the stress of the experience as possible.

46/24N E1109.4624N

E2110.2448L

EXAM 1-310

CORRIDOR 1-C-56

NURSE WORK 1-200

SU 1-506

RAD CONTROL 1-505A

CONSULT 1-504

CORRIDOR 1-C-58

NURSE WORK 1-300

TEAM CIRCULATION 1-300B

GEN RADIOLOGY 1-505

E3212.36F

ENT EXAM 1-211

OPTHALM 1-108

EXAM 1-203

LOUNGE 1-920

STORAGE 1-919

STAFF TLT 1-918

CAST/EXAM 1-509

733-66M

EEG/PFT 1-304

EXAM 1-204

EVS 1-917

WC SCALE 1-C-93B

? ?

CU 1-307

STORAGE 1-305

TOILET 1-210

CO212FF

CORRIDOR 1-C-54

ALCOVE 1-C-93C

WC SCALE 1-C-91A

CELL 01 STORAGE 1-209

CU 1-208

SU 1-207

TLT 1-205

TRASH/LINEN HOLD 1-916

CORRIDOR 1-C-93

CO561FL

EXAM 1-206

FEC-2

CO212FF

38/30E

ig s e

D s

e i t i l i ac

& n

ELEV E3

OFFICE 1-913

??^DY^??^?? E2665.3072L

MGR OFC 1-912

FEC-2

E2110.2472L

DN STAIRS S2-1

MDF 1-911

SECURITY DATA/ TELECOM 1-910

E2110.2448L

E2110.2442L

LOUNGE 1-909

CT136.10N

E2110.2448L

38/30E

E2841.33

E2844.30

COORD/PROG ASST OFC 1-908

AO610.1636

SLEEP MGR OFC 1-907

G6120.36DS

OPTHALM 1-107

CORRIDOR 1-C-52

AO610.1636

OPHTHALM SUBWAIT 1-106

AO610.1636

CT136.10N

G6120.36DS

CT136.10N

INF TLT 1-101F

ELEC 1-906

STAFF TLT 1-905

C3010.1336

FEC-2

CU - CELL 01 1-904

- efficiency of layout and flow of patients, staff and materials that cut down on cost and construction time - use of a linear layout of induction rooms, ORs and post-op spaces increase parent-child time - transitional indoor-outdoor spaces - adaptable staff work stations - staff work areas deep in the floor plate have little access to natural daylight

E2110.2460L

E2110.2466L

C3010.1336

AO610.1636

A3615.1636 AO610.1636

G6120.36DS

C3010.1336

G6120.36DS

R16

MED REC 1-903

A3615.1636

AO610.1636

A3615.1636 C3010.1336

G6120.36DS

AO610.1636

A3615.1636 AO610.1636 G6120.36DS

G6120.36DS

C3010.1336

TEAMING ROOM 1-902

E2110.2472L

E2110.2448L

Y2091.

AO610.1636

E2110.2472L

G6120.36DS

E2110.2472L

A3615.1636

AO610.1636

WORKROOM 1-901

E2110.2466L

A3615.1636

G6120.36DS

E2110.2472L

A3615.1636

E2110.2472L

C3010.1336

t s Te A3615.1636

E2110.2436L

E2110.2472L

g n i

Characteristics - four operating rooms with clean cores - regular and modular pod layout within the clinic - clear separation between front of house and back of house areas - design aesthetic that is playful yet appropriate to all ages within the pediatric patient spectrum A3615.1636

TYPE OF FACILITY Pediatric Surgery Center & Ambulatory Care Clinic

ARCHITECT(S) NBBJ

E2110.2472L

SQF 80,000

OWNER/AFFILIATION Seattle Children’s Hospital

E2110.2448L

SEATTLE CHILDREN’S BELLEVUE CLINIC

IV START 2-006

STORAGE

SEATTLE CHILDRENâ&#x20AC;&#x2122;S BELLEVUE CLINIC FLOWS & TYPES 1

4-5 5-7

& n

9 6-7

ig s e

D s

Patient Family Surgeon Anesthesiologist

8 2-3

4-5

2-3 2

2 1

Diagram Adapted From NBBJ by Rachel Matthews

1A 3

1. Admission a. Waiting 2. Height & Weight 3. Pre-Op Assessment / Induction 4. Surgery 5. Emergence 6. Post Anesthesia Recovery 7. Discharge

FAMILY 1. Admission a. Pre-Op Assessment 2. Waiting 3. Report from Surgeon 4. Post Anesthesia Recovery 5. Discharge

SURGEON

o f r

1. Change Clothes 2. Pre-Op Assessment 3. Check other patients 4. Scrub 5. Time-Out 6. Surgery 7. Dictating 8. Report to Family 9. Post Anesthesia 10. Check other patients

e t n e C

1. 2. 3. 4. 5. 6. 7.

2 1

3 2-3

10 6

4 4-9 3-5

Supplies/Medications/Disposables Sterile Instruments/Materials Movable Furniture or Equipmen

a F h

lt a e

NORTH

PATIENT

e i t i l i c

5-7 4

g n ti s Te

NORTH

SUPPLIES / MEDICATION / DISPOSABLES

ANESTHESIOLOGIST

Change Clothes Pre-Op Assessment Anesthesia Induction Time-Out Monitoring during surgery Anesthesia Emergence Post Anesthesia hand-off

Diagram Adapted From NBBJ by Rachel Matthews

1. 2. 3. 4. 5. 6. 7.

Storage/Pharmacy Storage & Inventory Staging for Surgery Surgery Waste Temporary Waste Storage Central Waste Storage (Exit building)

STERILE INSTRUMENTS / MATERIALS 1. Sterile Processing 2. Clean Staging a. Morning Staging 3. Storage and Distribution 4. Disassembly 5. Unpackaging & Inventory 6. Assembly 7. Surgery 8. Reassembly/Inventory/Cleaning 9. Cart Reassembly 10. Soiled Staging

MOVABLE EQUIPMENT 1. 2. 3. 4.

Central Storage Department Storage Cleaning Staging for Surgery

LESSONS LEARNED

Single direction flow reduces travel distance

Standardization removes waste

Significant efficiency can be gained by leveraging parallel processing through the use of dual induction rooms. By utilizing the induction room to perform all preoperative assessment and induction, one patient can be prepared for surgery concurrently while the prior surgery is closing and room turnaround is occurring. In this model, preoperative waiting for patients and their families is reduced to less than 3 minutes following check in.

Moving patients and staff through the system in one direction reduces travel distances for staff and provides increased efficiency due to reduced bed turns while transporting patients across the perioperative process.

Standardization of equipment and supplies in induction rooms, ORs and postoperative rooms reduces turnover time and allows staff to work across surgical phases, providing continuity of care while reducing the number of handoffs throughout the perioperative process.

e t n e C

o f r

e H r

h t l a

ig s e

D s

Parallel processing increases efficiency

e i t i l i c

& n

g n ti s Te

Privacy enhances the patient experience

Personalization supports family participation

Patients and their parents are afforded privacy throughout the perioperative process, as all exchanges of information are conducted in private spaces such as the induction room, consultation room or the postoperative room, providing a calm atmosphere that facilitates communication between providers and families.

A playroom dedicated to siblings of patients that is staffed full time by a child life specialist encourages both parents to participate in the surgical process up through induction and immediately following the surgical procedure in the PACU. In addition, parents are escorted through the perioperative process by a volunteer, reducing parent anxiety through increased access to information.

lt a e

F h

r e t n Ce

H r fo

t i l i ac

g n i t s 05 PROCEDURE MAPS e T & n DEFINITION g i s e D ies

As outlined in the AHRQ grant, a sampling of outpatient surgical procedures were videotaped and observed at the Main Hospital and Ashley River Tower facilities of the Medical University of South Carolina (MUSC) Health. This information was analyzed and coded to produce the following procedure maps which define the activities and location of the surgical team throughout all phases of intraoperative care. These include patient preparation, intra-operative, and post-operative. For the purpose of this study, patient preparation or pre-procedural care begins when the patient is received into the operating room. The intra-operative or intra-procedural phase begins at the time of induction. The post-operative or post-procedural phase begins at the point of emergence from anesthesia. Post-operative care concludes when the patient is transferred out of the operating room. The following procedure maps do not include turnover activities of setting up or breaking down each case. During turnover the floors, equipment, furniture and high touch areas are cleaned and disinfected by environmental services staff. Within the three phases care the surgical team, patient, furniture, and equipment are diagrammed relative to the location of the operating room table. The following sequence of diagrams includes: similarities across the procedure maps, individual diagrams of the surgeries, and differences across the procedure maps.

GOAL & PURPOSE The primary goal of these procedure maps is to document the nature and configuration of events and activities. Through this visualization the reader can follow the progression of the procedure and movements of the surgical team. Ultimately, these diagrams can be used to inform and visually assess various layout and design configurations.

PROCEDURE MAPS | SIMILARITIES SURGERY TYPE

g n i t s INTRAOPERATIVE | 00:00:00 e T & n g i s e D s

SURGERY PHASE | DURATION

NAME OF SURGERY

PATIENT PREPARATION | 00:00:00

DURATION OF SURGERY | 00:00:00 Short sentence describing the surgery and the type of patient.

LOCATION OF SURGERY ON PATIENT

a F h

IV STAND

DIAGRAM KEY Above Equipment Sterile Zone Movable Furniture or Equipment Zone Patient Circulating Nurse Zone Scrub Nurse Zone Surgeon Zone Anesthesia Zone

OR | BUILDING & ROOM NUMBER

• • • •

lt a e

H r fo

Patient transferred from Pre-Op to OR. Patient positioned on OR table by surgical team. Anesthesia induction. Back table set-up of instruments and supplies.

n e C

r e t

e i t i l i c • • • • • •

POSTOPERATIVE | 00:00:00

IV STAND

Patient is prepped and draped. Surgical team completes Time-Out. Back table, mayo stand, other furniture, and equipment is pulled up to the sterile zone. Scrub nurse has a relatively stationary role in the sterile zone. Anticipates and passes instruments and supplies to surgeon(s). Surgeons and anesthesiologists remain relatively stationary at the surgical site and head of the table respectively. Circulating nurse(s) has a mobile role outside of the sterile zone. Serves as the patient advocate by monitoring surgical practice and environmental conditions in support of a safe and error free experience. Procures additional instruments and supplies as needed.

IV STAND

• • • •

Anesthesiologist or anesthesia staff managed patient’s anesthesia emergence and extubation. Circulatin and scrub nurses initiate case break down and preparation of instrumentation return to SPD. Surgeon may exit the OR anytime between closing and patient transfer, or complete dictation. Patient is transferred to bed or stretcher and transferred to PACU by anesthesia and nursing staff.

PROCEDURE MAPS PEDIATRIC

PATIENT PREPARATION | 00:36:40

ESOPHAGEAL DILATION

Above Equipment Sterile Zone Movable Furniture or Equipment Patient Circulating Nurse Scrub Nurse Surgeon Anesthesiologist

OR | MAIN #5

TRASH

• • • • • •

e i t i l i ac

CART

TABLE

e t n e C

o f r

F h

lt a e IV STAND

Pediatric patient carried to OR by member of the surgical team. Circulating nurse and anesthesiologists or anesthesia staff position and secure the patient for induction. Patient anesthetized and intubated. Laproscopic tower moved into OR. Scrub nurse sets up intruments and supplies on back table. Patient preparation lasted longer than either of the other two phases.

ANESTHESIA MACHINE

EPIC EMR

ANESTHESIA MACHINE

TABLE

CART

TABLE

IV STAND

• • •

TABLE

TRASH

• •

EPIC EMR

MONITOR

Movable furniture positioned to the right side of the OR table. Scrub nurse in position to pass instruments to the surgeon at the head of the surgical table. Surgeons and anesthesiologists remained relatively stationary. Laproscopic tower utilized in conjunction with monitor across from the surgical table. Anesthesia zone accommodated three from the anesthesia team and two surgeons.

CART

TRASH

DIAGRAM KEY

POSTOPERATIVE | 00:14:21

STERILE INSTRUMENT TABLE

TABLE

D s

STERILE INSTRUMENT TABLE

CN STERILE INSTRUMENT TABLE

LOCATION OF SURGICAL SITE

ig s e

MONITOR

This surgery was a esophageal dilation which lasted approximately one hour.

& n

EPIC EMR

ANESTHESIA MACHINE

DURATION | 00:58:33

g n ti s Te

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IV STAND

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Anesthesiologist/anesthesia staff managed patient’s anesthesia emergence and extubation. Scrub Nurse assisted in cleaning up. Circulating Nurse assisted anesthesia staff with postprocedure patient management. Anesthesiologist/anesthesia staff placed patient in crib.

PROCEDURE MAPS PEDIATRIC

PATIENT PREPARATION | 00:33:00

GASTROCUTANEOUS FISTULA CLOSURE

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Pedatric patient carried into OR by member of the surgical team. Circulating nurse and anesthesiologists or anesthesia staff position and secure the patient for induction. Patient anesthetized and intubated. Scrub Nurse sets up intruments and supplies on back table. Patient preparation lasted longer than either of the other two phases.

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This surgery was a gastrocutaneous fistula closure in a pediatric patient

Above Equipment Sterile Zone Movable Furniture or Equipment Patient Circulating Nurse Scrub Nurse Surgeon Anesthesiologist

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CRIB

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Movable furniture positioned to the right side of the OR table. Scrub nurse in position to pass instruments to the lead surgeon on the right side of the table. Surgeons and anesthesiologists remained relatively stationary. Surgeons utilized scope in conjunction with the monitor across from the surgical table to perform the surgery. Member of anesthesia team monitored the surgery from the Epic EMR while the other remained at the head of the surgical table

• • • •

PROCEDURE MAPS PEDIATRIC

PATIENT PREPARATION | 00:05:41

OTO MYRINGOTONOMY WITH TUBE PLACEMENT

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This surgery was an oto myringotonomy with ear tube placement in a pediatric patient.

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DURATION | 00:30:01

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Small cart positioned to the right side of the table. Scrub nurse in position to pass instruments to the lead surgeon on the right side of the table. Surgeons and anesthesiologists remained relatively stationary. The lead surgeon performed the procedure utilizing a screen attached to the microscope on the opposite side of the patient. The assisting surgeon had to turn to view the microscope screen when necessary. Surgeons sat upon stools to perform the procedure. A member of the anesthesia team monitored the surgery from the Epic EMR while the other remained at the head of the surgical table.

VIDEO TOWER

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Anesthesiologist/anesthesia staff managed patient’s anesthesia emergence and extubation. Scrub Nurse assisted in cleaning up. Anesthesiologist/anesthesia staff placed patient in crib.

PROCEDURE MAPS PEDIATRIC

PATIENT PREPARATION | 00:11:02 CN

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DURATION | 00:18:51

This surgery was an oto bronchoscopy on a pediatric patient.

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Pediatric patient brought into OR feet first on stretcher. Circulating nurse and anesthesiologists or anesthesia staff position and secure the patient for induction. Patient anesthetized. Scrub nurse prepared the instruments and the video tower as well as aided in setting up the patient for surgery. Patient preparation lasted longer than either of the other two phases.

ANESTHESIA MACHINE

VIDEO TOWER

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POSTOPERATIVE | 00:06:06 VIDEO TOWER

EPIC EMR

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INTRAOPERATIVE | 00:01:43

The surgical table was rotated 90° clockwise in order for the surgeon to access the patient’s mouth with the scope while sitting down to perform the procedure. The video tower, positioned on the left side of the patient at the foot of the table, was utilized to assist the surgeon during the procedure. Scrub nurse in position to pass instruments to the surgeon. Surgeon and anesthesiologists remained relatively stationary. A member of the anesthesia team monitored the surgery from the anesthesia machine, another remained to the right side of the patient observing, and the other at the foot of the bed observing another monitor.

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Surgical table was rotated counter-clockwise 45° following the completion of the surgery. Anesthesiologist/anesthesia staff managed patient’s anesthesia emergence and extubation. Scrub nurse and circulating nurse assisted in cleaning up. A member of the anesthesia team transferred patient to hospital bed.

PROCEDURE MAPS ORTHOPEDIC

PATIENT PREPARATION | 00:13:16

TOTAL HIP ANTHROPLASTY (THA)

DIAGRAM KEY

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Orthopedic patient brought into OR feet first on stretcher. Patient assisted in transfer to surgical table. Patient anesthetized via spinal anesthetic. Surgeons took extended care and time to position patient. Scrub and circulating nurses prepared instruments needed for surgery.

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ANESTHESIA MACHINE

EPIC EMR

Scrub nurse positioned movable furniture around foot of surgical table. Scrub nurse in position to pass instruments to both surgeons. Surgeons and anesthesiologist remained relatively stationary. 1-2 circulating nurse(s) adjusted movable furniture, IV, and sat at work station.

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STERILE INSTRUMENT TABLE

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This surgery was a hip replacement on the patient’s right side, which lasted around three and a half hours.

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Small table moved to surgical table for convenient access to instruments needed for closing surgery. Anesthesiologist concluded case and monitors patient. Scrub nurse assisted in cleaning up. Patient transferred to hospital bed.

PROCEDURE MAPS ORTHOPEDIC

PATIENT PREPARATION | 00:22:42

TOTAL KNEE ANTHROPLASTY (TKA) DURATION | 3:30:00

ANESTHESIA MACHINE

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Orthopedic patient brought into OR feet first on stretcher. Patient assisted in transfer to surgical table. Patient anesthetized via spinal anesthetic. Scrub nurse prepared instruments needed for surgery.

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This surgery was a knee replacement on the patient’s right side, which lasted around three and a half hours.

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Surgeons took extended care and time in positioning the patient after the drape was up. Lead surgeon, on right side of the patient, repositioned surgical table (solid colored table) to be more centered in the sterile zone. Scrub nurse positioned movable furniture around foot of surgical table. Scrub nurse in position to pass instruments to both surgeons. Surgeons and anesthesiologists relatively stationary. 1-2 circulating nurse(s) adjusted movable furniture, IV, and sat at work station.

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POSTOPERATIVE | 00:23:22

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Anesthesiologists concluded case and transferred patient to bed. Scrub nurse, assisting surgeon, and circulating nurses assisted in cleaning up.

PROCEDURE MAPS BARIATRIC

PATIENT PREPARATION | 00:28:43

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Bariatric patient brought into OR feet first on stretcher. Patient assisted in transfer to surgical table. Patient anesthetized and intubated. Foot rests and arm rest positioned to accommodate the procedure. Patient’s left arm positioned on arm rest. Surgeons took extended care and time to position patient. Scrub nurses prepared instruments needed for surgery.

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This surgery was a laparoscopic gastric bypass surgery on a bariatric patient.

Above Equipment Sterile Zone Movable Furniture or Equipment Patient Circulating Nurse Scrub Nurse Surgeon Anesthesiologist

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Scrub nurses positioned movable furniture on the right of the patient at the foot of the surgical table. Scrub nurses positioned to pass instruments to the lead surgeon, located on the right side of the patient. Surgeons and anesthesiologist remained relatively stationary. A second surgeon observed the surgery before replacing the assisting surgeon to the left of the patient. 1-2 circulating nurse(s) adjusted movable furniture, IV, and assisted in moving instruments closer to the surgeons. Towards the conclusion of the surgery the patient was placed in the reverse Trendelberg position (surgical table rotated up approximately 45°) which utilized gravity to further facilitate the surgical procedure.

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Patient’s left arm was moved back to the surgical table. Anesthesiologists concluded the case and extubated the patient. Scrub nurse and circulating nurses moved movable equipment to beginning station. Scrub nurse assisted in cleaning up patient while circulating nurse aided in material clean up. Patient transferred to hospital bed.

PROCEDURE MAPS MATRIX OF DIAGRAMS | PEDIATRIC The surgeries previously diagrammed in this section document various pediatric, orthopedic, and bariatric surgeries. Diagrams on these two pages compare pediatric, orthopedic, and bariatric surgeries. The items highlighted in red are the differences across the four surgeries. The esophageal dilation required a laproscopic tower in conjunction with a flat-screen monitor and the anesthesia zone accommodated an unusual amount of people. A monitor was also used in the gastrocutaneous fistula closure in conjunction with a scope. During the oto myringotonomy with tube placement surgery a video tower was used in conjunction with a scope while both surgeons sat upon stools. The oto bronchoscopy surgery required a video monitor in conjunction with a scope as well as rotating the entire surgical table to accommodate the sitting surgeon. A hospital crib was not required unlike the previous pedatric surgeries due to the age of the patient.

DIAGRAM KEY Differences in comparison to other surgeries

PATIENT PREPARATION

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MATRIX OF DIAGRAMS | ORTHOPEDIC & BARIATRIC

POST-OPERATIVE

ESOPHAGEAL DILATION

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During the total hip anthroplasty (THA) the only notable difference in comparison to the other diagrammed surgeries was a small table was brought over the surgical table in order to complete the postoperative phase. The total knee anthroplasty (TKA) involved positioning the surgical table in a more central location relative to the surgical lights. Finally, the laparoscopic gastric bypass surgery involved arm and foot rests, an electric rotating table, as well as an overlay of a small table to perform the operation. Overall, there were very few differences in the surgeries.

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g n i t s 06 ADVISORY COMMITTEE e T & n g i s e D s e i lit

The technical advisory committee comprises of individuals with expertise in clinical, operational and design aspects of surgery. Several of these individuals bridge different areas of expertise. The role of the advisory committee members is to provide technical input and guidance during all phases of the project. They serve as the external â&#x20AC;&#x2DC;sounding boardâ&#x20AC;&#x2122; for the research team and allow for the project findings and design solutions to be grounded in practice. They also ensure that the findings have broader relevance beyond MUSC.

ADVISORY COMMITTEE

BILL BERRY | M.D., MPA, MPH

Bill Berry, MD, MPA, MPH is chief medical officer at Ariadne Labs. In this role, Bill oversees the growth and development for all the research work including the Program teams: Safe Surgery, BetterBirth, and Serious Illness Care as well as the Platform teams: Informatics and Measurement, Implementation and Improvement Science, and Program Management. In addition, Bill serves as the Director of the Safe Surgery Program and oversees the specific research and execution of the program. Bill is also a Surgical Consultant to the Risk Management Foundation of the Harvard Medical Institutions and serves as the Boston Program Director of the “Safe Surgery Saves Lives” initiative with the World Health Organization’s Patient Safety Program. For the last eight years, Bill has been a faculty member the Institute for Healthcare Improvement in collaborative projects focused on improving the safety of surgical patients. Prior to these roles, Bill spent seventeen years in practice as a cardiac surgeon. Bill earned his MD from Johns Hopkins University School of Medicine and achieved his board certification in general surgery, thoracic surgery, and surgical critical care. He earned his MPA from Harvard Kennedy School of Government and his MPH from Harvard School of Public Health.

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Tim Brookshire, MBA is the Senior Administrator for Perioperative and GI Services for the Greenville Health System. In this capacity, he has operational, financial and strategic responsibility for this Service Line throughout the Upstate to include 8 facilities representing over 60 operating and procedure rooms which provide care to over 40,000 patients annually. Tim joined GHS in 2014 and prior to that was a Vice President with Carolinas Healthcare System in Charlotte North Carolina where he served as an administrator with Carolinas Medical Center since 2006. Prior to that, Tim worked as a consultant for the North Carolina Department of Health and Human Services and also investment banking analyst program with Lehman Brothers in New York. A native of Asheville, NC, Tim holds an MBA from the Kenan-Flagler Business School at the University of North Carolina as well as a BA in Economics and Political Science from UNC. He has previously served as the preceptor for the Administrative Fellowship program and has held adjunct faculty positions at the University of Alabama Birmingham and Xavier University. He is married to Blake, with 2 children, Adam and Marie and enjoys traveling, running and non-fiction. He is active with St. Matthew United Methodist Church and serves as the Treasurer for the Mackenzie Foundation, an Asheville-based non-profit.

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DAVID CULL | M.D.

KEITH ESSEN | PH.D., MSN, BSN

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David Cull, MD received his medical doctorate from Baylor College of Medicine in Houston, Texas, and completed his residency in general surgery at Wilford Hall Medical Center in San Antonio, Texas. He was a vascular surgery fellow at Eastern Virginia Graduate School of Medicine in Norfolk, Va. Dr. Cull is a Fellow of the American College of Surgeons, the Southern Surgical Association, the Southern Association for Vascular Surgery, the Society for Vascular Surgery, the Peripheral Vascular Surgery Society, and the Southeastern Surgical Congress. He is the Professor Vice Chair of Academics Department of Surgery at the University of South Carolina School of Medicine, Greenville Health System. Dr. Cull has been employed with the Greenville Health System in the Department of Surgery for nearly 18 years. During this period, he has been involved in the conception, planning, and implementation of a number of programs and systems that have improved patient care. Dr. Cull developed a network of hospitals and surgeons throughout Greenville County that focused on improving the quality of vascular access surgical care delivered to patients on hemodialysis. That network involved 23 surgeons and 2 hospitals and included a database for research and quality improvement. Keith Essen, PhD, MSN, BSN is a recently retired Active Duty Army Colonel. He has held multiple roles both as a Nurse Executive and as a Director of multiple medical center operating rooms. Keith attained CNOR certification and has spoken nationally at the annual AORN Convention multiple times. He has extensive experience serving as a staff nurse, OR course Director for 4 years, and as the Perioperative Nursing Director of 4 Army Medical Centers culminating as the Director of Perioperative Nursing at Walter Reed Army Medical Center. Keith was appointed by the Army Surgeon General in 1999 as the Perioperative Nurse Consultant. While serving in that role he was the Co-Leader in setting up the Patient Safety Program at Landstuhl Regional Medical Center in Germany. As a consultant Keith served during a pivotal time as the emphasis on patient safety culture evolved subsequent to the IOM report “To Err is Human”. He oversaw the Army’s initiative to develop the Universal Protocol for Surgical timeouts. Keith earned his PhD from Uniformed Services University for the Health Sciences. His dissertation was a structural equation model on safety culture. Keith has extensive management experience and is a recognized speaker nationally. He has conducted numerous presentations both locally and nationally on strategies to overcome Toxic Work Environments, Organizational Structural failures that impede safety and efficiency and an array of other issues. Currently Keith is employed with the Veterans Administration National Center for Patient Safety and assigned to the Central Office in Washington, DC.

ADVISORY COMMITTEE Eileen Malone, RN, MSN, MS, EDAC is the Senior Partner for Mercury Healthcare Consulting, LLC located in Alexandria, Virginia, who supports clients embracing evidence-based design in health facility projects, as a means to help improve healthcare outcomes. With over forty years in healthcare, Ms. Malone retired from the United States Army in 2004 having held a variety of key leadership positions including hospital commander (CEO), Army Medical Department CIO, Congressional Affairs Officer, quality assurance nurse, and in several internal medicine nurse practitioner assignments. She holds graduate degrees from Duke University and the National Defense University and is Evidencebased Design Accredited and Certified. In addition to many military awards, Eileen received The Center for Health Design’s (CHD) Changemaker Award in 2009 and the Leadership Award from the Health Information and Management Systems Society in 2004 for her leadership in the creation and implementation of a patient centered information technology strategy for the Army Medical Department. Now semi-retired, Ms. Malone devotes time to volunteer consultant activities related to the use of evidence-based design to help improve healthcare outcomes. From 2008 to 2013, EILEEN MALONE | RN, MSN, MS, EDAC Eileen served as a member of CHD’s Research Coalition and as its co-chair for the last two years of her tenure. She was a member of the Facility Guideline Institute’s Board of Directors and 2014 Healthcare Guidelines Revision Committee. Most recently, Eileen was a member of the Secretary of Defense’s Independent Review Panel on Military Medical Construction Standards, which provided detailed recommendations for the Department and Congress in two reports. Ms. Malone continues to explore the relationship between healthcare reform quality improvement targets and evidencebased design opportunities, through the delivery of national-level presentations, the creation of CHD white papers, and as an active member of numerous grant advisory boards for research around these topics.

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John Schaefer, MD is an international expert in healthcare simulation who is transforming the way healthcare clinicians are taught, and in the process, helping to reduce patient injury and improve medical outcomes. Dr. Schaefer came to South Carolina from the University of Pittsburgh where he helped establish the WISER Institute. He served as director of the center from 1997 to 2006 and directed the multi-partnered expansion of the center. In South Carolina as a SmartState Endowed Chair, he has led the effort to establish a statewide network of 14 simulation programs including universities, technical colleges and health systems that now perform over 80,000 patient simulations annually. This network of collaborative simulation centers now provide training for medical, nursing and allied health students, as well as advanced continuing education to hospital employees and physicians in South Carolina, North Carolina and Alabama. They allow healthcare providers to practice their skills in a controlled, risk-free environment, rather than in an actual patient setting. This innovative training method results in better healthcare outcomes and increased patient safety. Additionally, Dr. Schaefer has established a number of industry relationships resulting in new innovations in simulation that are making South Carolina a leader in the medical simulation field. He co-founded a start-up company called SimTunes in 2008 to create and commercialize simulation educational technology and in 2015 was awarded a presidential citation from the international Society for Simulation in Healthcare for his contributions to the field of simulation globally.

Jonas Shultz, MSc, EDAC works as a Human Factors Lead with the Health Quality Council of Alberta, and has 10 years’ experience working in medical human factors. He has provided human factors expertise to a variety of healthcare organizations, including Alberta Health Services, Health Canada, ISMP Canada, and the Center for Health Design in the United States. He is also an adjunct lecturer with the Department of Anesthesia, Cumming School of Medicine with the University of Calgary. The majority of Jonas’ work has focused on evaluating the design of built environments for healthcare, such as hybrid operating theatres or ambulances, minimizing human error during medication administration, and testing the usability of medical devices. Jonas has published his work in peer reviewed papers and has been an invited speaker at numerous national and international organizations and conferences.

JONAS SHULTZ | MSc, EDAC

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g n i t s 07 WHATâ&#x20AC;&#x2122;S NEXT?e T & n g i s e D s e i lit

The intent of the learning lab was to collect a body of information that would help identify gaps in knowledge around OR systems design as well as opportunities for improvement in the OR. The work conducted this year provides an excellent foundation for the future phases of the RIPCHD.OR learning lab. During the upcoming year, the learning lab will focus on designing and developing key concepts to address opportunities around creating a safer OR. A range of different design and process interventions will be developed and tested through physical and virtual simulation. Part of the next phase of the project is to focus on the design and development of a physical operating room mock-up. This mock-up is being investigated by eight Masters of Architecture + Health (M.Arch+Health) students who are currently in their final year of study. In order to build the mockup several smaller scale models will be constructed. These smaller models will aid in testing different equipment configurations and locations of items including patient entrance, staff entrance, booms, movable furniture, electrical outlets, various team membersâ&#x20AC;&#x2122; workstations, storage equipment and etc. Meanwhile, another group of nine students in the M.Arch + Health program are focusing on designing an entire orthopedic ambulatory surgery center. This effort is based on a current project underway with the Medical University of South Carolina in West Ashley. Understanding the process of moving a patient through the surgery center as well as the role a healthcare entity plays in a community is key in designing the facility.

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OVERVIEW A key goal for the next phase of the RIPCHD.OR learning lab is to move from the problem analysis phase into the design and development phase for all the projects. The key activities that will be undertaken in 2016-2017 to support the goals of the overall learning lab include:

BRAINSTORMING WORKSHOP A brainstorming workshop will be conducted on September 19-21 at the Clemson Architecture Center at Charleston (CACC). Participants will include the RIPCHD.OR learning lab team, technical advisory committee members and industry experts. The key focus of this workshop is to: • Present study ﬁndings and learn from experts about trends in surgery that will impact the learning lab • Identify high priority areas for design improvements that may impact patient and staff safety in the OR • Prioritize a small set of projects for the learning lab to undertake in year 2 • Conduct a design workshop with research team, industry experts, advisory committee and graduate students from Clemson’s Architecture + Health program ARCHITECTURE + HEALTH DESIGN STUDIO FOCUSING ON SURGICAL SUITE DESIGN: The second year graduate students led by Prof. David Allison in the A+H program in Architecture at Clemson will undertake a deep-dive design project focusing on the OR. The design concepts developed through this effort will be used to develop the OR prototype. Prof. Byron Edwards will be leading a group of ﬁrst year graduate students in the A+H program through a design project focused on the new Orthopedic Ambulatory Surgery center at MUSC. David Allison and Anjali Joseph along with Prof. Byron Edwards are also teaching a seminar course on Operating Room Design and Operations to allow students to obtain a deep understanding of the OR from a systems perspective.

DEVELOPMENT AND TESTING OF SIMULATIONS AND PROTOTYPES OF VARYING LEVELS OF FIDELTIY: The three project teams will all develop different prototypes based on their project foci to test early design concepts. The prototypes will be evaluated using table-top simulations or in the physical mock-up that will be built at the CACC. The simulation center at MUSC will be used to develop and test key scenarios of use for the OR mock-ups that are developed. The team will also work on developing detailed protocols (OR use scenarios and scripts) that will be used to test the performance of different iterations of the products (e.g. anesthesia work station, OR layout) that are mocked up.

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DEVELOPMENT AND TESTING OF ANESTHESIOLOGY WORKSTATION In year 2, project team 1 will complete the construction of the prototype anesthesiology task workstation that will simulate the tasks, sounds and environment within which the anesthesiologist works. This will include a workstation, displays and speakers that play the noises that occur in the OR, and will allow the integration of advanced display technology. The team will continue to evaluate different display means, i.e. sensory modality or heads up display corresponding to varying levels of task complexity, and dynamic environmental characteristics for the anesthesiologist. This phase will also involve creating a simulated operating room scenario and varying factors such as mental workload and presentation modality (visual, auditory, and tactile).

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DEVELOPMENT AND TESTING OF PHYSICAL MOCK-UPS AND OR SCENARIOS In collaboration with the MUSC ASC team, the most promising concepts will be developed in detail by the research team. An initial low fidelity mock-up will be constructed at full scale at the Clemson Architecture Center at Charleston, and movable equipment and supplies will be brought into this space. In parallel, several OR surgery scenarios will be developed to illustrate process disruptions and conflicts that were observed during problem analysis. The scenarios will then be used to test the efficacy of proposed design solutions.

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DEVELOPMENT AND TESTING OF DESIGN FLOWS THROUGH VIRTUAL SIMULATIONS Using the prototype simulation from Year 1, enhancements to the decision-making capability in the model will be added to allow each person in the OR to react to changes in his/her surroundings. In other words, we can test new design layouts and ﬂow suggestions without having to recommend changes to the actual system.

COORDINATION WITH MUSC ASC PROJECT DESIGN TEAMS We will set up a process of regular information sharing and coordination between RIPCHD.OR and the architecture ﬁrm working on the new ambulatory surgery center that is being planned in North Charleston.

DATA ANALYSIS AND DISSEMINATION The teams will complete the coding of videos and continue to analyze the data collected during the problem analysis phase. This information will be disseminated through journal publications and conference presentations. Additionally, the team will share project findings with surgical leaders in the SC Surgical Quality Collaborative. The intent will be to obtain feedback on the broader relevance of our findings and also to disseminate study findings widely in SC and nationally.

ITERATIVE TESTING AND DESIGN IMPROVEMENTS These simulations will be video-recorded and analyzed by team members to identify areas of conflicts. An on-site evaluation tool (a precursor to the OR safety risk assessment tool) will be developed at this stage and used by study participants to objectively evaluate and rate different aspects of the physical mock-up from the perspective of patient safety and efficiency. This process will yield quick feedback on changes that need to be made to the designs. Modifications will be made to the designs and parallel changes made to increasingly higher fidelity physical mock-ups as the schedule and budget allows (for example, by changing room boundaries or shape, location of doors, fixed and movable equipment positioning, medical gas/electrical/communication interfaces, location of storage etc). Two to three rounds of testing and design modifications are anticipated over the course of year 2 and year 3 of the learning lab. At each stage, the designs will be refined and more detail added to the OR room mock-up.

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STUDIO DESIGN PROJECTS

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OUTPATIENT ORTHOPEDIC AMUBLATORY SURGERY CENTER | WEST ASHLEY, SC

PHYSICAL OR MOCK-UP | CHARLESTON DESIGN CENTER (CDC), DOWNTOWN

BYRON EDWARDS, AIA, ACHA, EDAC, LEED AP PROFESSOR OF PRACTICE IN ARCHITECTURE + HEALTH This semester long project is for a 100,000 + sf Ambulatory Services Campus Masterplan on MUSC’s new Ambulatory Campus in West Ashley area of Charleston, SC. The first Phase Design Project is a 40,000 square foot Orthopedic Ambulatory Surgery Center for the Medical University of South Carolina’s (MUSC’s) Musculoskeletal Institute. The Ambulatory Surgery Center will include the following departments; Surgery, Imaging and future Clinic. The Surgery is planned for 2 ORs and 3 Procedure Rooms with ability to expand in the future. At a minimum, this Project should address MUSC space program needs, but it should also address a holistic approach to healing and address the innovative integrative and alternative medical and non-medical healing concepts of the mind, body and spirit in terms of dealing with the internal and external influences of a truly healing environment. The project should also address the Health of the Community at large in its environmental and contextual responses. The design should address the specific environmental issues of the site including topographic, vegetation, soils, site access, and utilities, but it should also consider and address the specific health, cultural, racial, socio-economical, and political issues within the Community and pay homage to the importance of this specific site and its contextual significance in that Community.

DAVID ALLISON, FAIA, FACHA DIRECTOR OF GRADUATE STUDIES IN ARCHITECTURE + HEALTH The goal of the studio this semester is to build from and contribute to an ongoing Realizing Improved Patient Care through Human-Centered Design [RICHRD.OR] AHRQ funded multi-year research effort, and design then build a full-scale operating room mock-up at the Clemson Design Center in Charleston. This mock-up and its design features are to serve as a test prototype for an optimal, adaptable and flexible ambulatory surgery OR “platform” or “chassis.” It will be executed as part of an interdisciplinary research-design-researchredesign project involving architecture and health students and faculty in collaboration and consultation with researchers, clinicians, consultants, practicing architects and industry collaborators. The project to be designed this semester is intended to build upon prior research knowledge and best practices to address and advance current design thinking and solutions employed in health care architecture and equipment design in the Operating Room. We hope to reflect and support both the art and science of healthcare, and demonstrate that interdisciplinary design built upon a rigorous and systematic study of issues, problems, opportunities and constraints can raise the quality, safety, efficiency and adaptability of design in healthcare contexts while addressing a broad range of patient, staff and family needs.

MASTER OF ARCHITECTURE + HEALTH STUDENTS FIRST SEMESTER OF PROGRAM

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CAROLINE WYRICK

LANSING DODD

MALONE HOPKINS

SHAHROOZ BEHESHTI

LANEY TUTEN

MEGAN GIRVAN

WENZ TUTTLE

LUKE DAVIS

SHICONG CAO

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MASTER OF ARCHITECTURE + HEALTH STUDENTS THIRD SEMESTER OF PROGRAM

RACHEL MATTHEWS

YINGCE HUANG

LEAH BAUCH

ZHIQIN (JANE) LIU

SHIRUI (MAX) LIN

LINDSEY HOFSTRA

QIAN (KENNETH) DONG

AUSTIN FERGUSON

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THE PHYSICAL MOCK-UP | CONSIDERATIONS CONDUCTING A SIMULATION-BASED MOCK-UP EVALUATION JONAS SHULTZ, MSc EDAC

Human Factors Specialist Health Quality Council of Alberta & Adjunct Lecturer Department of Anesthesia, Cumming School of Medicine, University of Calgary

Patient and staff safety as well as other patient and staff outcomes are strongly linked to the built healthcare environment in critical ways. The physical space, equipment, and people within any healthcare environment have a bearing on patient care and experience. The Simulation-Based Mock-up Evaluation Framework (available from www.hqca.ca/humanfactors),1 developed by the Health Quality Council of Alberta, outlines an approach to collect and analyze data from mock-up healthcare environments. Specifically, it outlines an approach to collect and analyze data from full scale mock-ups, through the use of simulation, where individuals enact processes and procedures that will be performed in the space. A simulation-based mock-up evaluation should be thoroughly planned to maximize effectiveness. Evaluation objectives, which outline what will be tested for both design and outcomes, need to be identified. These are often determined by the design team in collaboration with the evaluator or evaluation team. Together the objectives form the intended scope of the evaluation and are critical for many subsequent steps in the evaluation process. Previously conducted simulation-based mock-up evaluations of an operating room have focused on physical space issues, equipment access, workflow inefficiencies, patient monitoring, communication issues, default room configuration prior to patient arrival, role clarity, and team performance. 2,3

objectives. The degree to which a mockup is completed (mock-up fidelity) can vary significantly. The mock-up should be built to an appropriate level of fidelity to enable testing of evaluation objectives during the appropriate design phase. Roles and responsibilities for those involved in the evaluation should be clearly defined. This includes identifying who will be responsible for evaluation design, staging the mock-up, data collection, and data analysis as well as who will participate in the scenario enactments. The simulation scenarios that are created and enacted should test the evaluation objectives. Evaluating a mock-up involves selecting frequent, urgent, and challenging tasks to create simulation scenarios that will test predetermined evaluation objectives. The scenarios are enacted by users of the space within the mock-up, which includes needed supplies and equipment (real or mock-ups). The simulations should include participation by all users of the space which may include health care workers, support staff, patients, families and representatives from key components and disciplines (e.g., infection prevention and control, health and safety).

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Photo (courtesy of DIALOG) shows a C$6 million interventional trauma hybrid operating room at the Foothills Medical Center in Calgary, Canada. Simulationbased mock-up evaluations were conducted during room design and commissioning. Design based recommendations, most of which were implemented, resulted in measurable improvements to quality and patient safety.

Photo (courtesy of Alberta Health Services) shows a mock-up used to evaluate the design of a C$6.6 million cardiac hybrid operating room at the Mazankowski Alberta Heart Institute. The room, which opened in 2014, enables cardiologists and surgeons to work together, on the same patient, in the same room, at the same time.

Recommendations should be informed by evidence-based data from scenario enactments. Evidence-based data, collected through user feedback and video analysis, is used to identify potential issues and successes with the planned design. The recommendations that are developed should address any identified issues.

[1] Health Quality Council of Alberta. Simulation-Based Mock-up Evaluation Framework. Calgary, Alberta, Canada: Health Quality Council of Alberta; March 2016.

Iterative design, a concept that involves testing, analyzing, and refining design through a cyclical process, can occur by repeating Building of the mock-up should align with evaluation timing and simulation scenarios to retest design modifications.

[3] Biesbroek, S., Shultz, J., Kirkpatrick, A., & Kortbeek, J. (2012). Human factors evaluation of an interventional trauma operating room mockup. Proceedings of the 2012 Symposium on Human Factors and Ergonomics in Health Care (pp. 73 - 78), Baltimore, MD: Human Factors and Ergonomics Society.

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[2] Kirkpatrick, A., Vis, C., DubĂŠ, M., Biesbroek, S., Ball, C., Laberge, J., Shultz, J., Rea, K., Sadler, D., Holcomb, J., Kortbeek, J. (2014). The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: The RAPTOR. Injury; 45(9), 1413-1421.

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FUTURE PHYSICAL OR MOCK-UP CONFIGURATION OPTION

AF104 - OPTION C1

AF108 - OPTION D1

AF105 - OPTION C2

AF109 - OPTION D2

AF102 - OPTION B1

AF103 - OPTION B2

AF101 - OPTION A1

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[DRAFT] NOT FOR CONSTRUCT

701 East Bay Street, Charleston, South Carolina 29403 | Clemson - Suite 130

C.D.C. | DURING CONSTRUCTION

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AF106 - OPTION C3

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THE CIGAR FACTORY | OR MOCKUP

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(Below) In collaboration with MHED LLC and McMillian Pazdan Smith architects, plans are underway to construct the structural frame to begin the physical mock-up of the OR. Efforts with the mock-up began in May 2016 with drawing a 3D model of the existing structure in the Charleston Design Center (CDC). The use of Building Information Modeling has aided the team in visualizing what the space will look like as well as coordinate with the required building consultants in order to begin construction. (Right) BIM has also allowed the display of a variety of options. With the structural system designed and installed by MHED the team will be able to implement a variety of configurations if necessary. Before install the team anticipates testing out configurations virtually to inform the initial installation. After collaboration with a group of M.Arch+Health students a different configuration may be installed and ultimately further tested by the research team. All in all computer modeling the space has enabled the team to further understand and grasp the different elements which influence the location of items in the OR, i.e. the patient bed, doors, booms, and etc.

AF107 - OPTION C4

THE PHYSICAL MOCK-UP

Sheet Issue Date 160829

A104

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