RIPCHD.OR Volume 3 by Clemson Center for Health Facilities Design & Testing

Modeling

OUTCOMES

t Organizational

l En

vir

PROCESSES

Externa

Medical devices, electronic medical records, supply carts, booms, surgical lights, communication tools, alarms

Technology &Tools

Organization

Professional Work Collaborative Care Team Patient Work

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

Enviornmental hazards, layout, noise, lighting, temperature, humidity, air, work station design, surgery table, alarm, doors, storage, etc.

Education, experience, certiﬁcation, skills, knowledge, physical and psychological characteristics, cognition abilities, etc.

Tasks

1 2

PROJECT

WORK SYSTEM

UNMASKING Specify anesthesia work station ANESTHESIAand technology design RELATED ALARMS & interventions to unmask alarms COMMUNICATIONS or mitigate the effects of masking

PROCESS

Patient Outcomes: -Number of SSI for orthopedic cases 4 5 -Time to SSI

Use a systems approach to analyze patient, equipment, materials, supplies, staff and information

Identify the factors that impact ﬂow and cause disruption, and modify processes accordingly

Minimize ﬂow disruptions in ﬁve categories: 6 - Usability related - Layout related - Environmental hazards - Interruptions - Equipment failure

Operational Outcomes: - Duration of anesthesia 7 - Duration in OR - Total OR time - Number of cases per OR per day

Design an ergonomic and human centered OR

Develop a framework (concept of operations or functional program) that describes evidence and best practice processes in the OR

Patient

ADAPTATION

Study framework for RIPCHD.OR learning lab is based on the SEIPS 2.0 framework by Holden and colleagues 11

Without Induction

22' - 0"

HOW TO GET STARTED?

Low-medium fidelity mock-up evaluation

OR Flow Modeling Tool

High fidelity mock-up evaluation

Task Switching Analysis

HOW TO MAKE MY CONCEPT REAL?

N FINDINGS INTO AN NITY FOR DESIGN?

Safe OR Design Tool

lt a e

e t n e C

H r o f r

O.R. 579 SF

Organizational Outcomes: -Cost reduction – avoidance for SSI -Regulatory Survey pass

Enhance the performance of the surgical team - Use of Safe Surgical Checklist - Prophylactic IV antibiotic timing Improve workﬂow within the team Enhance visibility of work and team members

Patient Outcomes: - Number patients transferred or admitted to the hospital - Number of cases of surgery on the wrong patient, site or side - Number of adverse events associated with sedation for GI procedures 8 - Incidence of ortho SSI - Intra and post-operative bleeding for tonsillectomy patients 9

Minimize distractions of team members Reduce risk of surgical site infections

Care Team Outcomes: -Number of OR staff needle/sharp injuries and blood and body ﬂuid exposure 10 -Number of OR staff trips, slips, falls and other injuries *Improve OR efﬁciency - Number of cases/day/room/specialty

& n g i s

g n ti s Te

e D s

e i t i l i c a F REALIZING IMPROVED PATIENT h

14' - 3"

Flows Mapping tool

Care Team Outcomes: -Team member satisfaction survey scores

Minimize impacts of ﬂow disruptions INTEGRATED OR SUITE DESIGN

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

OUTCOMES

Minimize the frequency and duration of door openings to improve air quality 3 -Number of door openings -Number of minutes door open per case -Room pressure mean inches H2O -Number of cases with <0 pressure -Percent of time case in line with regulatory air pressure standard

Care Team

(1) American Society of Anesthesiologists. (2013). Statement on principles for alarm management for anesthesia professionals. (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, total operation time https://www.facs.org (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 (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 – 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 infections, since it is the most common complication following pediatric surgical procedures, other than transfusion; recommend that we look at orthopaedic cases. (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 incisional SSI complication https://www.facs.org (6) Palmer, G., Abernathy, J., Swinton, G., & Arch, M. (2013). Realizing Improved Patient Care through Human-centered Operating Room Design. Anesthesiology, 1-12. (7) 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, total operation time https://www.facs.org/ashx (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 procedures. http://www.aapd.org/media/policies_guidelines/g_sedation.pdf (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 – 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 infections, since it is the most common complication following pediatric surgical procedures, other than transfusion; recommend that we look at tonsillectomy cases. (10) CDC (2011). The National Surveillance System for Healthcare Workers (NaSH): Summary Report for Blood and Body Fluid Exposure Data Collected from Participating Healthcare Facilities (June 1995 through December (2007) https://www.cdc.gov/nhsn/pdfs/datastat/nash-report-6-2011.pdf (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.

PROCESS OUTCOMES

Specify processes to unmask Anesthesiologist/nurse anesthetist Organizational Outcomes: alarms or mitigate the responds in a timely fashion (Look at -Duration of anesthesia 2 -Duration in OR effects of masking organization’s Alarm Management Policy for a deﬁnition of this parameter) 1 -Total OR time -Number of cases per OR per day to critical physiologic changes (O2, ETCO2, NIBP, HR, etc.) - Fewer incidents of delayed intervention to critical changes in physiologic measures Identify and mitigate the factors contributing to door openings

PEMSI FLOWS IN OR Specify design and process interventions to help minimize door openings and ﬂow disruptions

Patient Work

Environment

26' - 0"

IF YOUR ORKING?

WORK SYSTEM

14' - 3"

n Tool

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

6’

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

VOLUME 3-4 | 2017-2019

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

EXECUTIVE SUMMARY

g n ti s Te

Previous attempts to reduce adverse events in the operating room (OR) focused on enhancing skills and training for the clinicians involved in the direct care of the patient. However, little effort has been directed at the built environment within which healthcare providers work. Research in complex settings suggest that adverse events are often caused by a combination of active and latent failures (inherent in the system) and interventions that target these systemic factors are often more efficacious than approaches that focus exclusively on individual characteristics. The overarching goal of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Learning Lab (PSLL) titled, â&#x20AC;&#x153;Realizing Improved Patient Care through Human centered Design in the Operating Roomâ&#x20AC;? (RIPCHD.OR) was to develop an evidence-based framework and methodology for the design and operation of operating rooms, such that it impacts improved perioperative outcomes including surgical site infections, surgical errors and staff injuries. While the focus of this study is specifically on the OR, we acknowledge that factors outside the OR may influence operations and work processes. The Center for Health Facilities Design and Testing (CHFDT) at Clemson University collaborated with the Medical University of South Carolina (MUSC) to develop the RIPCHD.OR learning lab. Moving from problem analysis, design and development in the first two years, the third year of the RIPCHD.OR PSLL focused on implementing concepts into a prototype OR and into the new ORs at MUSCs pediatric ASC, evaluating outcomes in the live and simulated settings, disseminating findings via peer reviewed and conference presentations, workshops and developing a Safe OR Design Tool.

& n g i s

e D s

e i t i l i c a F h

This unique and productive collaboration between two universities, each including faculty and students from multiple disciplines such as healthcare architecture, human factors, simulation, operations management, nursing and anesthesia, resulted in 18 peer-reviewed journal publications, 47 presentations at national and international conferences and multiple mentions in the media including in the Wall Street Journal. Most significantly, RIPCHD.OR has resulted in the design of a safer and more efficient OR work system and physical design prototype that addresses the dynamic interactions between OR users (staff and patient), the tasks they need to perform and the technology and built environment they interact with. Over the past three years, the OR prototype has been visualized, experienced and evaluated in cardboard form, using virtual reality, as a high-fidelity physical mock-up, and most recently as a fully built OR in a live ambulatory surgery center. The team has not only hosted visitors to the OR mock-up at the Cigar Factory in Charleston, but we have taken the prototype OR on the road and shared it with hundreds of children and adults at the ACC Simthsonian Creativity and Innovation Festival held at the National Museum of American History in Washington, DC.

lt a e

H r o f r

e t n e C

This final book provides a summary of the RIPCHD.OR project, focusing specifically on work completed in years 3 and 4. The design and phased construction of the OR mock-up, and iterative scenario-based evaluation comprised a key component of the work undertaken between 2017-2019. This design, construction and evaluation work involved not only the RIPCHD.OR faculty and students, but also our technical advisory committee, pediatric and orthopedic surgical teams,

g n ti s Te

and our key industry partners. The final OR prototype is the result of this iterative, multiple stage process. Chapter 3 provides a summary of some of the empirical studies published by the teams. The graphical abstracts for each of these studies summarizes the significance of the study, methods, results and takeaways. The findings from this body of work serves as a foundation for the web-based Safe OR Design Tool that is described in Chapter 4.

& n g i s

The multidisciplinary RIPCHD.OR team has also been creative in developing new approaches or modifying existing established methods to address unique research challenges. The project has resulted in a series of tools ranging from using task analysis and simulation modeling to evaluate future OR designs, to video observations and coding to obtain fine grained information about interactions within the OR work system. This book provides a brief introduction to some of these tools.

e D s

One of the key tools developed as part of RIPCHD.OR is the Safe OR Design Tool. This tool brings together much of the work from years 1 to 4 of this project and is intended to serve as an accessible and user-friendly resource for teams designing new ORs or renovating existing ones. The tool is based on published literature as well as the knowledge gleaned by the RIPCHD.OR team through the iterative design and evaluation process. Its intuitive and graphic interface allows teams to understand how key design decisions related to different OR design elements may impact patient and staff safety, as well as experience and efficiency.

e i t i l i c a F h

lt a e

RIPCHD.OR is poised to come full circle as we look forward to understanding how the RIPCHD.OR prototype was implemented in MUSCâ&#x20AC;&#x2122;S new R. Keith Summey Pavillion in Charleston, SC. The facility opened in April 2019, and admitted its first pediatric outpatient surgery patients soon after. The RIPCHD.OR team will conduct its post-occupancy video observations and evaluation in late 2019 and early 2020. The team will compare behavior patterns and outcomes in the new ORs with the data collected in years 1 and 2 of the project.

e t n e C

H r o f r

The PSLL allowed the RIPCHD.OR team to mobilize the expertise of this incredible multi-disciplinary group of experts, faculty and students to understand the OR worksystem in greater depth than has been attempted previously. Further, the systems engineering framework of the PSLL facilitated the transition from understanding to design innovation and implementation. The RIPCHD.OR team is extremely grateful to AHRQ for this incredible opportunity and for developing the vision for this PSLL grant mechanism. This project is truly the result of the tireless effort and support of so many beyond the RIPCHD.OR research team and collaborators. This includes the leadership at both universities, grants management teams, financial and administrative teams, colleagues, friends and families. We look forward to continuing this journey with you all to make healthcare environments safer and more human-centered.

& n g i s

g n ti s Te

e D s

e i t i l i c a F h

lt a e

H r o f r

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 official views of the Agency for Healthcare Research and Quality.

e t n e C

EDITORS: Rutali Joshi, Anjali Joseph, Deborah Wingler, David Allison EDITORIAL ASSISTANTS: James Lyndon McCracken GRAPHIC DESIGNERS: Rutali Joshi, Hannah Shultz, Ray Tan, Herminia Machry, Graduating class of A+H program 2017

TABLE OF CONTENTS

e t n e C

r o rf

01 02 03 04 h 05 t l a 06 e H 07 08

Project Overview

e D s

& n g i s

g n ti s Te 01 - 14

Prototype Development Phases & Simulation

15 - 38

PSLL Research Studies

39 - 54

Methods Toolkit

55 - 76

Future State OR

77 - 88

Next Steps

89 - 92

e i t i l i c a F Dissemination

Team Acknowledgments

93 - 110 111 - 120

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

Project Overview

& n g i s

g n ti s Te

The Realizing Improved Patient Care through Human Centered Design in the OR (RIPCHD.OR) patient safety learning lab (PSLL) was set up to create a strong multidisciplinary network of people and places that together could effectively address patient safety issues in the OR. Chapter 1 of this book describes the organizational set up and team structure of the learning lab. The Systems Engineering Initiative for Patient Safety (SEIPS 2.0) by Holden and colleagues was adapted, by the teams as a common study framework. This widely used human factors systems model provided a strong theoretical foundation that was followed by each team through every phase of the project, ranging from the video observations in year 1 and coding during problem analysis to evaluations in the high-fidelity OR prototype. Though each specialized team independently addressed various unique challenges in the OR through subprojects, the framework offered a grounding to integrate and translate the research findings into strategies that enable building safe and more ergonomic ORs. In addition, chapter 1 highlights the project milestones and key achievements that have occurred during the 4-year RIPCHD.OR learning lab.

e D s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

PROJECT PARTNERS

g n ti s Te

The core research team for the RIPCHD.OR PSLL is comprised of university faculty, design researchers, healthcare architects, human factors engineers, operations management researchers, and clinicians. The learning lab received expertise and support from a diverse group of clinicians from MUSC and industry partners across the nation. Additionally, the team also received guidance from an advisory committee comprised of clinicians, architects, patient safety and quality experts from national and international organizations like Greenville Health System, Health Quality Council of Alberta, Ariadne Labs and The Center for Health Design.

Dr. Scott Reeves (Principal Investigator)

RIPCHD.OR PSLL

Anesthesiology

Medical University of South Carolina

lt a e

Nursing

H r o f r

Perioperative Services Quality and Safety

e t n e C

Quality & safety experts

Anesthesiologists Surgeons Nurses

e D s

e i t i l i c a F h Industry partners

Surgery

& n g i s

Operations management researchers

Dr. Anjali Joseph (Principal Investigator) Architecture+Health School of Architecture Department of Industrial Engineering

Clemson University

School of Nursing

College of Business

Technical advisory committee

College of Computing

Clinical & patient advisory committee

Administrative staff

Human factors experts

Healthcare architects

Design researchers

University faculty Graduate students Doctoral students

PROJECT NETWORK

& n g i s

g n ti s Te

e D s

e i t i l i c a F h

lt a e

H r o f r

e t n e C

Clemson Team MUSC Team Industry Partners Advisory Committee Members

CORE TEAM

g n ti s Te

The core team is led by principal investigators- Dr. Anjali Joseph from Clemson University and Dr. Scott Reeves from MUSC. The learning lab is comprised of three distinct but highly interrelated patient safety focused projects related to the key aspects of safety in the OR. Each project was structured to be led by two project leaders- one from Clemson University and one from MUSC to facilitate closely coordinated efforts between the two organizations. The core team is supported by a program coordinator. The work of the learning lab is supported by several masters and doctoral students from Clemson Universityâ&#x20AC;&#x2122;s Department of Industrial Engineering, College of Business, School of Architecture and School of Computing.

& n g i s

e D s

PRINCIPAL INVESTIGATORS

e i t i l i c a F h

lt a e

e t n e C

H r o f r

ANJALI JOSEPH | PH.D., EDAC CLEMSON UNIVERSITY

SCOTT REEVES | M.D., MBA, FACC, FASE MEDICAL UNIVERSITY SOUTH CAROLINA

CORE TEAM | YEAR 3-4

YEAR 3

e D s

e i t i l i c a F h

PROJECT LEADER | TEAM 1

PROJECT LEADER | TEAM 2

PROJECT LEADER | TEAM 3

DAVID NEYENS | PH.D., MPH

KEVIN TAAFFE | PH.D.

DAVID ALLISON | FAIA, FACHA

CLEMSON UNIVERSITY

& n g i s

CLEMSON UNIVERSITY

g n ti s Te

JAMES ABERNATHY | M.D.

MEDICAL UNIVERSITY SOUTH CAROLINA

lt a e

H r o f r

e t n e C

PROGRAM COORDINATOR JAMES McCRACKEN

CLEMSON UNIVERSITY

DEBORAH WINGLER | PH.D. CLEMSON UNIVERSITY

KEN CATCHPOLE | PH.D.

MEDICAL UNIVERSITY SOUTH CAROLINA

SARA BAYRAMZADEH | PH.D. CLEMSON UNIVERSITY

TEAM MEMBERS

YEAR 4 TEAM MEMBERS

PROJECT 1

DAVID NEYENS

PREVIOUS TEAM MEMBERS

SCOTT REEVES

PROJECT 2

KEN CATCHPOLE

KATIE JUREWICZ

e t n e C

KYLIE GOLMES

SCOTT BETZA

LAWRENCE FREDENDALL

SEYED AMIN SEYED HAERI

CASSANDRA SALGADO

DEE SAN

& n g i s

YANN FERRAND

AMIN KHOSHKENAR

MARISA SHEHAN

ALEXIS FIORE

EMILY HUFFER

BRANDON LEE

MIRANDA MUS

e D s

e i t i l i c a F h

lt a e

H r o f r

SARA RIGGS

KEVIN TAAFFE

JAEYOUNG KIM

DOTAN SHVORIN

g n ti s Te

ROXANA JAFARI

DAVID ALLISON

DEBORAH WINGLER

HANNAH SHULTZ

lt a e

e t n e C

LANSING DODD

SARA BAYRAMZADEH

WENZ TUTTLE

ZAHRA ZAMANI

RACHEL MATTHEWS

RAY TAN

& n g i s

HERMINIA MACHRY

RUTALI JOSHI

AMANDA REDDING

ERIC BOLIN

e D s

e i t i l i c a F h

HEATHER HINTON

H r o f r

JAMES ABERNATHY

SUSAN Oâ&#x20AC;&#x2122;HARA

PREVIOUS TEAM MEMBERS

ANJALI JOSEPH

BILL ROSTENBERG

LEAH BAUCH

g n ti s Te YEAR 4 TEAM MEMBERS

PROJECT 3

JAMES DOMINIC

PROJECT TIMELINE 2015

-Mock-up design

YEAR 2

2017

H r o f r

e t n e C YEAR 4 2018

lt a e

-Design development & implementation at MUSC

-Testing & evaluation -Development of OR design toolkit

& n g i s

e D s

The focus of Year 2 of the learning lab was primarily on moving from problem analysis to design and development in the three integrated and interrelated sub-projects within the larger project. Project 1 incorporated findings from year 1 into the anesthesia workstation prototype. Project 2 developed a platform for interaction with a simulation model to represent a surgical procedure. Project 3 developed OR design concepts that were implemented and built into mock-ups of increasing levels of fidelity.

e i t i l i c a F h

2016

YEAR 3

g n ti s Te

Year 1 of the project focused on structuring the learning lab, formalizing the vision and goals for the overall project and three sub-projects, as well as establishing infrastructure and management. An extensive literature review was followed by visits to exemplar facilities, data collection through video observations and data analysis. To conclude the first year of the project and transition from problem analysis to conceptual design, a design charrette and project visioning session was held with all project team members, MUSC clinicians, design professionals, advisory committee members, and Clemson Architecture + Health graduate students.

-Literature review -Case studies -Observations

YEAR 1

In year 3, project teams worked to integrate sub-projects into a single system to be incorporated into the high-fidelity OR prototype. The team used an integrated systems approach to explore the dynamic interactions between the people, OR physical, environment, workflows, equipment, and technology through scenario based simulations conducted in the mock-up. One of the key activities undertaken in year 3 has been constructing a high-fidelity OR prototype and initiating the development of a Safe OR Design Tool. The final year of the RIPCHD.OR PSLL focused on implementation, evaluation and dissemination. Findings from prior years and observational data from the full surgery simulation conducted in year 4 were used to refine the OR prototype, evaluate outcomes in the simulated setting and develop a Safe OR Design Tool. Moreover, with the completion of the new ORs at MUSCâ&#x20AC;&#x2122;s pediatric ASC, the team will undertake post-occupancy evaluations to obtain operational and safety data to compar with the retrospective data obtained in Year 1 of the project.

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

PROCESSES

l En

Externa

Medical devices, electronic medical records, supply carts, booms, surgical lights, communication tools, alarms

Organizational

Technology &Tools

e D s

Professional Work

Collaborative Care Team Patient Work

e i t i l i c a F h

Person

Enviornmental hazards, layout, noise, lighting, temperature, humidity, air, work station design, surgery table, alarm, doors, storage, etc.

& n g i s

Organization

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

UNMASKING ANESTHESIARELATED ALARM COMMUNICATIO

OUTCOMES

vir

WORK SYSTEM nm

Tasks

r o rf

Patient Work

Environment

alt

ADAPTATION

e t n e C

physical and psychological characteristics, cognition abilities, etc.

Environmental hazards, layout, noise, lighting, temperature, humidity, air, work station design, surgery table, alarm, doors, storage, etc.

Patient

Study framework for RIPCHD.OR learning lab is based on the SEIPS 2.0 framework by Holden and colleagues 11

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

PEMSI FLOWS IN

Care Team

Education, experience, certiﬁcation, skills, knowledge, physical and psychological characterEducation, experience, istics, cognition abilities, etc. certification, skills, knowledge,

g n ti 1 s Te

PROJECT

Medical devices, electronic medical records, supply carts, booms, surgical lights, communication tools, alarms

INTEGRATED OR SUITE DESIGN

Teamwork coordination, collaboration, work schedules, management style,Table on-time developed by Eile performance, etc.

PROJECTS RIPCHD.OR

& n g i s

PROJECT 1

YEAR 1

Design development

YEAR 3

3D Gestural input study

e H r o rf

e t n e C Design implementation

Anesthesia workstation design

TASK SWITCHING

Video capture observation & coding

alt

YEAR 2

GESTURAL STUDY

e D s

e i t i l i c a F h

Anesthesia alarms

Problem analysis

PROJECT 2

Tactile display study

Microbial load study

Circulating nurseâ&#x20AC;&#x2122;s workflow study

Discrete event simulation modeling

Design and traffic flow improvement simulation modeling

OR FLOW MODELING

DISPLAYS & ALTERNATIVE INFORMATION PRESENTATIONS

YEAR 4

Evaluation and dissemination

CONTAMINATION OF ANESTHESIA WORK AREAS

g n ti s Te

POST OCCUPANCY EVALUATIONS IN THE NEW MUSC ASC

g n ti s Te PROJECT 1

& n g i s

PROJECT 3

e i t i l i c a F h

Flow analysis

Literature Review

alt

e H r o rf

e t n e C

OR DESIGN TOOLKIT

e D s

Indepth case studies & international best practices

ANALYSIS OF DOOR OPENINGS IN THE OR

CAPACITY MODELING

COMMUNICATION & TURNAROUND TIME

BENEFITS OF A STERILE INSTRUMENT SETUP ROOM OR A SEPARATE INDUCTION ROOM ADJACENT TO THE OR

Procedure maps PROJECT 2 Traffic flow and door openings in the OR

OR VR experiment

OUTCOMES DATABASE

Unmasking of anesthesiarelated alarms and communications

Development of OR prototype, mock-up & simulation

HIGHER FIDELITY MOCK-UP, SIMULATION AND EVALUATION

PROJECT 3 Integrated OR suite design

LIVE HIGH FIDELITY SIMULATIONS AND EVALUATIONS

PROJECT ACCOMPLISHMENTS January-April 2016 Problem Analysis & coding protocol February-May 2016 Behavior observations of the OR system

SeptemberDecember2016 Literature Review

PROBLEM ANALYSIS

DESIGN & DEVELOPMENT

lt a e

H r o f r

IMPLEMENTATION

EVALUATION & DISSEMINATION

YEAR 1

e t n e C

August 2015

& n g i s

August 2016 Case studies & focus groups

e D s

e i t i l i c a F h

g n ti s Te

October 2016 Tape on the floor mock-up

June 2016 Space acquired for mock-up

November 2016 Cardboard mock-up

December 2016 Higher fidelity cardboard mock-up

April 2016 onward Data analysis of videos

YEAR 2 August 2016

September 2016 RIPCHD.OR Workshop & design charrette September 2016 RIPCHD.OR Volume 1

January 2018 High fidelity mock-up unveiling RIPCHD.OR Workshop & OR design tool ideation session June 2017 Construction of high fidelity mock-up begin

YEAR 3

May 2018 Nursing task simulations in high fidelity mock-up

e t n e C

November 2017 Evidence based design Touchstone award (silver category) November 2017 Healthcare Environments Award (conceptual design)

March 2019 MUSC announces new surgery center September 2019 Post-move evaluations

YEAR 4 August 2018

May 2018 â&#x20AC;&#x153;The Operating Room of the Futureâ&#x20AC;? featured in The Wall Street Journal January 2018 RIPCHD.OR Volume 2

& n g i s

e D s

e i t i l i c a F h

lt a e

H r o f r August 2017

September 2018 Workshop at Leo A Daly, FL

March 2018 Anesthesia task simulations in high fidelity mock-up

October 2017 ACCelerate Creativity and Innovation Festival, held at the National Museum of American History in Washington, DC.

g n ti s Te

December 2018 Full team scenariobased simulations in high fidelity mock-up

August 2019

February 2019 Workshop with Emory at Charleston November 2018 Featured in the Healthcare Design Magazine Joseph, A. & Allison, D. (2018). Designing a Safer OR. Healthcare Design Magazine

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

Development of OR prototype, simulation & mock-up

& n g i s

g n ti s Te

Graduate students from the Architecture+Health program translated the research findings from year 1 into design ideas confirming the design guidelines that were developed based on evidence-based design goals. The designs were tested iteratively through OR mock-ups of increasing levels of fidelity starting with tape on the floor, cardboard mock-ups, and virtual reality. In the third year, the designs were refined based on prior evaluations. The Clemson Design Center in Charleston was remediated to support the construction of the high-fidelity mock-up. The high-fidelity prototype includes overhead booms and lighting, integrated displays, and OR equipment (including surgical table, gurney, anesthesia workstation, mobile circulating nurse workstation, etc.). This OR prototype was used throughout year 4 for additional testing specific to each team or across teams. Design elements, processes and technologies were tested in the mock-up by engaging clinicians and other medical personnel in the scenario based surgical simulations.

e D s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

PROJECT PHASES

& n g i s

Build

Understand

Ideate

Interpret

Design

ies

t i l i c a F h

DeďŹ ne

ReďŹ ne

H r o f r

lt a e

Literature review & Observations

e t n e C

Data collection & Data analysis

YEAR 1

Design Charette

Development of Design guidelines

Test

g n ti s Te

Evaluate

Disseminate

Implement

Synthesize

Translate

Iterative design process

YEAR 2

Construction of ASCs

YEAR 3

Post occupancy research

Develop design toolkit

YEAR 4

g n ti s Te

PROBLEM ANALYSIS

This step involved conducting a literature review, understanding the clinical environment through observations and case studies, observing clinical processes and procedures, reviewing records, conducting focus groups, interviewing stakeholders, and identifying potential products, systems and materials.

DESIGN

The findings from problem analysis phase were translated into design ideas, concepts and design guidelines through brainstorming during a design charrette. This phase was meant to challenge designers to â&#x20AC;&#x153;think beyond the orthodoxyâ&#x20AC;?. Each design phase was followed by the construction of mock-ups with increasing levels of fidelity.

DEVELOPMENT

& n g i s

e D s

e i t i l i c a F h

Several components of the OR (OR size and layout, layout of anesthesia area, sight lines and visibility, lighting, design and positioning of the surgical table, location of doors, ceiling mounted booms, location of supplies, equipment storage, work flows, innovative displays and technology) as well as processes and technologies (gestural displays) were evaluated individually and as part of an integrated system in the mock up. This helped to identify and refine any neglected or unrecognized linkages in the sociotechnical work system. This testing was performed with clinicians and other medical personnel.

lt a e

H r o f r

IMPLEMENTATION

Some design concepts tested in the simulated OR environment were implemented in a new pediatric ASC.

EVALUATION

Post occupancy evaluations will be conducted in the new ASC once occupied.

e t n e C

Henriksen, K., Rodrick, D., Grace, E. N., Shofer, M., & Jeffrey, P. B. (2019)

DEVELOPMENT OF DESIGN GUIDELINES

g n ti s Te

The development of design guidelines began during the design charrette at the end of Year 1, with identifying the aim of the project to be quality and safety in the OR. This aim was informed by five evidence-based design goals. The design guidelines were developed throughout the design process to address multiple evidence-based design goals. Each guideline was expanded upon with definitions, significance and implementation strategies.

& n g i s

The design guidelines served as a means of informing the design process, as well as a future way of evaluating the design, and are reflected in many of the design decisions that were ultimately made.

e D s

EVIDENCE-BASED DESIGN GOALS

e i t i l i c a F h

OPTIMIZE THE ABILITY TO CHANGE OVER TIME OPTIMIZE SUSTAINABLE STRATEGIES

Maintain staff retention and satisfaction in the work place

lt a e

H r o f r

OPTIMIZE CLINICAL OUTCOMES, HEALTH & SAFETY

e t n e C

Spatial continuity from operation to operation, day to day and future growth

Maintain patient comfort and satisfaction of services and, environmental interactions

Assessment of recovery time, surgery effectiveness, minimize patient readmission due to error Protecting staff and patient well-being, avoiding preventable complications, etc

OPTIMIZE POSITIVE EXPERIENCE FOR ALL USERS

Maintain staff retention and satisfaction of work place

OPTIMIZE OPERATIONAL EFFICIENCY & EFFECTIVENESS

Maximizing patient and staff outcomes while minimizing errors, time, and need for redundancy in the operating room

Maintain patient comfort and satisfaction of services

QUALITY & SAFETY IN THE OR

PROJECT VISION

& n g i s

g n ti s Te

e D s

EVIDENCE-BASED DESIGN GOALS

OPTIMIZE EFFICIENCY & EFFECTIVENESS

lt a e

H r o f r

DESIGNte n GUIDELINES e C

e i t i l i c a F h

PLAN THE O.R. TO OPTIMIZE MAXIMIZE VISUAL MOVEMENT AND AWARENESS IN THE O.R. FLOW

OPTIMIZE CLINICAL OUTCOMES AND HEALTH & SAFETY

PROVIDE INTEGRATED DIGITAL INFORMATION DISPLAYS IN MULTIPLE

LOCATIONS

MINIMIZE INSTITUTIONAL CLUTTER

OPTIMIZE POSITIVE EXPERIENCE FOR ALL USERS

PROVIDE APPROPRIATE & CONTROLLED ACCESS TO DAYLIGHT

OPTIMIZE SUSTAINABLE STRATEGIES

PROVIDE FLEXIBLE & CONTROLLABLE ARTIFICIAL LIGHTING

OPTIMIZE THE ABILITY TO CHANGE OVER TIME

DESIGN FEATURES THAT MINIMIZE SURFACE AND AIRBORNE CONTAMINATION

INCORPORATE PLUG & PLAY SYSTEMS

EMPLOY A FLEXIBLE ROOM / SUITE CHASSIS

DESIGN STAGES

FLOOR PLAN | 1+2

PLAN DRAWINGS

22' - 0"

A.Z.

g n ti s Te

595 NSF

FGI MIN | 400 SF SC a MIN DIMENSION | 20 FT

A.Z.

SINGLE CORRIDOR OR

C.Z.

14' - 3"

SC b

GB&A

SINGLE CORRIDOR

26' - 0"

S.Z.

C.Z.

& n g i s S.Z.

13' - 0"

Option D

DOOR

26’-0”

C GB&A

14' - 3"

FLOOR PLAN | 1

22' - 0"

S.Z.

A.Z.

Option B B

A.Z.

Flex Studio

C.Z. S.Z.

Anesthesia Zone Scrub Nurse Zone Circulating Zone 12' - 3 1/2"

S.Z.

CLEAN CORE

C.Z.

595 NSF

FGI MIN | 400 SF MIN DIMENSION | 20 FT

12' - 3 1/2"

Option A

C GB&A

DOOR

Anesthesia Zone Scrub Nurse Zone Circulating Zone

15' - 0"

12' - 3 1/2"

26’-0”

Option C 12' - 3 1/2"

C.Z.

DOOR

S.Z.

30’-0”

C.Z.

13' - 0"

DOOR 12' - 3 1/2"

12' - 3 1/2"

Seminar

OR OR

SINGLE CORRIDOR

Design Refinement

Design Development

SC b

Preliminary Design

SINGLE CORRIDOR

CACC Studio

Option B

584 NSF

Option A

FGI MIN | 400 SF SC a MIN DIMENSION | 20 FT

Option A

Anesthesia Zone Scrub Nurse Zone Circulating Zone

e t n e C

26' - 0"

r o rf DOOR

INDUCTION

22’-0”

INDUCTION

CACC Studio

INDUCTION

OR INDUCTION

S.Z.

26’-0” 24’-0”

SINGLE CORRIDOR INDUCTION

A.Z.

OR INDUCTION

Option B

C.Z.

Seminar

INDUCTION

A.Z.

FLOOR PLAN | 3+4

DOOR

alt DN

587 NSF

13' - 0"

30’-0”

DOOR

A.Z.

Option C

FGI MIN | 400 SF SC c MIN DIMENSION | 20 FT

14' - 3"

t i l i c a F h

Flex Studio

13' - 11"

C GB&A

DOOR

14' - 0"

S.Z.

26' - 0"

ies

22’-0”

13' - 0"

C.Z.

22' - 0"

14' - 3"

26’-0” 24’-0”

Option D

15' - 0"

FLOOR PLAN | 5

26' - 0"

14' - 0"

A.Z.

Anesthesia Zone Scrub Nurse Zone Circulating Zone

12' - 3 1/2"

22' - 0"

12' - 3 1/2"

Pediatric

Orthopedic Without Induction

With Breakdown

22' - 0"

A BREAKDOWN

26' - 0"

14' - 3"

& n g i s

C GB&A

14' - 3"

e D s

Option C

26' - 0"

e t n e C Option A

Option B

14' - 3" 14' - 3"

Without Induction

22' - 0"

Option A

Anesthesia Zone Design Refinement

INDUCTION 206 SF

O.R. 579 SF

14' - 3"

r o rf

ALCOVE 206 SF

26' - 0"

alt

Option B

14' - 3"

Option B

13' - 9"

14' - 3"

c a F h

e i t i il O.R. 579 SF

15' - 0"

13' - 9"

With Induction

22' - 0"

13' - 9"

Option C

g n ti s Te

6â&#x20AC;&#x2122;

Option A

Overall Design Refinement

MOCK-UP SIMULATION FINDINGS KEY CONCLUSIONS October, 2016

November, 2016

December, 2016

Room size

Position of surgical table

Chasis configuration (clean core, work core, single corridor)

Location of digital displays, storage, staff work areas, and scrub sink

Door location

Concepts for ancillary induction and preparation rooms

Equipment placement and orientation

c a F h

s e i ilit

& n g i s

g n ti s Te

Entrance and exit sequence

Location of induction and prep room in relation to the foot of the bed Content and location of digital displays Number and location of doors in relation to sterile CN zones

lt a e

H r o f r

e t n e C

Tape on the floor simulation

Initial cardboard mock-up simulation

Higher fidelity cardboard mock-up simulation

March, 2018

May, 2018

Gestural interactions

December, 2018

& n g i s

Layout- angled bed, 1 door versus 2 doors

Locations of workstation components (work surface, anesthesia machine, EMR computer)

Location of equipment

Location of equipment/furniture in anesthesia zone (IV pole, glove box, sharps container, pyxis machine)

g n ti s Te

e D s

Placement of circulating nurse and surgeon workstation

e i t i l i c a F h Information displays

Holistic system evaluation in high fidelity scenario-based orthopedic and pediatric simulations.

Change in work flow due to induction room and instrument prep room

lt a e

H r o f r

e t n e C

High fidelity mock-up simulation Anesthesia zone evaluations

High fidelity mock-up simulation Nursing evaluations

6 High fidelity mock-up simulation Systems Evaluations

MOCK-UP SIMULATION FINDINGS KEY CONCLUSIONS October, 2016

November, 2016

e D s

Wall-mounted screens should be placed above the workstation

Doors should be located on the longer side of the room

Storage doors should require less space

Alcove can accommodate mobile equipment

e i t i il

Wall-mounted screens are preferred by anesthesia team & surgeons for the distance provided between them & the screens

Both circulating nurse and anesthesia team need equivalent of one tall Pyxis for storage

e t n e C

& n g i s

The “plug and play” feature should be advanced

View from the scrub sink to the OR is necessary

Diagonal placement of the OR table supported smooth transition of patient gurney to the OR table side

r o rf

December, 2016

c a F h

alt

Circulating nurses favored mobile workstations Angled bed position works well in different situations

g n ti s Te

Surgeon’s workstation should remain far from traffic Must have two workstations Phone and glove dispenser required for anesthesia zone Anesthesia booms should be parallel and behind the anesthesia machine The displays should be lowered to minimize head/neck movement Sliding doors are favored to swing doors

Door location should be away from the sterile field

Tape on the floor simulation

Initial cardboard mock-up simulation

Higher fidelity cardboard mock-up simulation

March, 2018

May, 2018

Option A supported increased visibility, allowing providers to see all the equipment in front of them, as well as more unobstructed views to the wall-mounted displays.

December, 2018

Using an induction room is most beneficial for pediatric cases where parents participate in the induction process and some adult spinal cases (Option B).

e i t i l i c a F h

lt a e

e t n e C

& n g i s

e D s

Using an instrument preparation room is most beneficial for longer surgeries, creating the potential for having one instrument preparation room serve multiple ORs. However, this type of arrangement would impact staffing models (Option C).

H r o f r

g n ti s Te

PEDIATRIC SIMULATIONS

Multiple screen with patient vitals support anesthesia team members collective tasks. Room layout allows bed to rotate, keeping unobstructed circulation space for all surgical team members and without encroachment into anesthesia zone.

ORTHOPEDIC SIMULATIONS The ability for the boom to be positioned on either side of the foot of the bed was crucial for reducing encroachment into the anesthesia zone. Displays in 3 locations were key to facilitating information access to all surgical team members. The display of multiple types of information simultaneously was key to supporting surgical team membersâ&#x20AC;&#x2122; individual and collective tasks. The height of displays was considered to be too high. Modifications to height should take into account placing screens at a height where movable equipment will not bump into them.

High fidelity mock-up simulation Anesthesia zone evaluations

High fidelity mock-up simulation Nursing evaluations

6 High fidelity mock-up simulation Systems Evaluations

MOCK-UP EVALUATION phase 1-5 6 sessions of mock-up evaluations were conducted during the iterative design process. To evaluate the variations of the prototypes, an evaluation toolkit was developed. The evaluation toolkit helped to gather feedback from the simulations in a structured manner to inform the next phase of the design process.

Master protocol

alt

e H r o rf

Simulation director’s guide

Note takers template

e t n e C

& n g i s

Overview of goals, scenarios and design feature tested

Scenario details for each surgical phase Evaluation objectives Scenario tasks Equipment and supplies list Design features tested Evaluation questions Photo protocol

e D s

e i t i l i c a F h

Phases 1-5 included an overall framework for conducting evaluations that contained:

MASTER PROTOCOL

g n ti s Te

Appendix Stakeholders Equipment used for each scenario

Task/scenario Patient entry into room and transfer to surgical table Pre-operative positioning of teams and equipment (based on procedure map) Preoperative tasks for different team members  Anes task related to accessing storage  Circulating nurse/scrub task related to accessing internal OR storage  Time out – look at large screen as a team to go through time out. Circulating nurse directs time out from her table? Transition from pre-operative positioning to intra-operative positioning of teams and equipment  Team members will orient themselves and the equipment to align with the different side of the surgical table  Teams simulate intra-operative position and tasks  Teams simulate specific tasks that may require them to view the large screen  Team simulate specific task that requires the anesthesiologist to access supplies, dispose trash Transition from intraoperative to postoperative positioning of teams and equipment  Scrub simulate disposal of trash  Circulator – epic documentation  Surgeon- epic documentation

Design features tested Door location Sidedness and impact on the CN and sterile zone location Sink location Distance to anesthesia storage for anesthesia team Ease of accessing storage (any obstructions?) Access to large screen for information

Surgical table sidedness Access to anes storage Access to circulating nurse storage Number and location of large screens and monitors Type of information that would be useful to display

Surgical work station location Circulating nurse workstation Display screen needs

Patient is transferred from room  Room clean up  Team discussion re next patient

Door size Door location Surgical table sidedness

Turnaround/room set up  Incomplete case cart – nurse has to obtain supplies, instruments from core  Instrument tray sterility problems – replace or run emergency sterilization load  Circulating nurse/ SN gathers items stored in OR

Door location Storage location

SIMULATION DIRECTORâ&#x20AC;&#x2122;S GUIDE

NOTE TAKERS TEMPLATE

& n g i s

g n ti s Te

Pre-brief and recap of last evaluation

Floor plan of configuration being tested

Meeting goals

Participant contribution

Evaluation scenarios c. How often Task during a surgery would you need to get those? anyone else on the team who would need to get to the supplies located d. Is thereDesign features tested

Checklist for each scenario phase Task Evaluation question Yes/No check box Notes

c a F h

in this anesthesia cabinet? e. Is the location of storage near the CN convenient for everyone on the team? f. Are there any obstructions to using the CN storage? Debriefing questions g. Where do you want the storage in the room? h. How much needs to be in the room?

lt a e

ENACTMENT: You will be playing a number of scenarios, which helps us evaluate the effectiveness of the adopted design strategies in the OR. You will not be evaluated on how you perform task, but we will be looking at the space accommodation for the tasks to which you are assigned. Before enacting each scenario, we will review the scenario and read it aloud to remind the details that may have been missed.

H r o f r

DISCUSSION/FOCUS GROUP: During the enactment, we will be asking the players and observers to discuss some of the topics that need more input and explorations. These topics are the location and quantity of storage for anesthesia personnel and CN, location and content of the displays, and number of door to separate the travel paths for the CN and patient, and surgical table sidedness.

e t n e C

THINK ALOUD: While acting you may express your thoughts on the action needed and how you see the space supporting or hindering that. For example, if I were enacting the role of a nurse in the scenario and was hooking up an IV pump that needs to be plugged in, I might say that I need to plug in the pump and that there are no conveniently located electrical outlets. There are no right or wrong comments, so please speak freely. If you forget to state your thoughts out loud, I may occasionally prompt you to continue to do so. DEBRIEF: If you forget to mention something during a scenario, you will also be given an opportunity to have a reflective conversation through debriefing at the end of each scenario. For those involved in the scenario, I will be conducting the debriefing. For observers who were not directly involved in the scenario, [insert name of debriefing facilitator] will be conducting the debriefing session. For all design options: Jake to introduce the overall scenarios and tasks to all team members and then have them run through the surgery. Direct the team when they should transition from one stage (pre-op) to next. Try to remove yourself from what you have always done. Build upon your experience These are questions we would like you to focus on:

e i t i il

e D s

Detailed debriefing questions for each plan Common debriefing section (open ended)

PREOPERATIVE PHASE PREOPERATIVE PHASE

Task

Evaluation question

Bed transfer

Does the transfer bed move through the room and rotate easily given the amount of space and surgical table placement and surgery sidedness? Is there enough space around the surgical table and gurney to facilitate transfer of patient? Is there anything that is blocking the anesthesia provider when they move from the anesthesia workstation to the supplies?

Stretcher brought in

Anesthesia task related to accessing storage (TBD)

Are there any bumps or challenges maneuvering the gurney? Is there a clear path of movement from the door to the surgical table?

check Notes

Where is the ideal storage location for the anesthesia personnel? How much storage is needed for the anesthesia personnel?

Surgeon enters and reviews patient information at surgical workstation. Discusses surgery with team members

Is there a clear path of travel for the surgeon to access the workstation? Is there enough space around the surgical workstation for the surgeon to confer with team members? Does there appear to be any conflict when the surgeon and nurse are at the shared workstation at the same time?

Time Out on large screen in the room

Is the circulating nurse able to lead the time out discussion from her station? Can all team members view the timeout screen?

Additional questions and notes:

RIPCH.OR MOCKUP SIMULATION SUMMARY â&#x20AC;&#x201C;December 2016 |

MOCK-UP EVALUATION

g n ti s e VIDEO RECORDINGS OF SIMULATIONST & n g i s e D s e i t i l i c a F h

phase 6

Full simulations were conducted with surgical teams consisting of a scrub nurse, circulating nurse, surgeon, and two anesthesia personnel for the following procedures •Orthopedic Arthroscopy •Pediatric Laparoscopic hernia repair •Pediatric Ear tubes and tonsillectomy

Use video recordings to capture details of the simulation using 4 Noldus cameras mounted at strategic locations and linked to a base computer. The videos were analyzed using the Observer XT (version 12.5) analysis software

A multi-layered data collection approach was implemented to evaluate the effectiveness of alternative design options in addressing the EBD goals. Video recordings

lt a e

H r o f r

Systems observation

e t n e C

BREAKDOWN

Path of travel and FD mapping Post-enactment survey and focus groups Visual awareness interview Debriefing

cameras mounted on poles

base machine & computer screen cameras mounted on poles

connections - camera to computer base machine & computer screen connections - camera to computer ﬁeld of view

ﬁeld of view

INDUCTION

e t n e C

Location of SFDs on plan

Type of SFD (details of environmental and layout related SFDs) START TIME -

SHEET NO.#

(with induction room)

COMMENTS COMMENTS

LAYOUT LAYOUT

Wire Infraction

Bumps

com

Excessive Reach

ENVIRONMENTAL

Impeded view (posture change)

Work system based on SEIPS framework

EXAMPLES OF SAFETY RELA

ROLE - Circulating Nurse SIMULATION - Pediatric Laproscopic hernia repair

Cluttered pathway (posture change)

Please mark note-taker location on plan

Obstacle (route change)

NOTE-TAKER -

ORGANIZATION

H r o f r SETUP

Path of travel for each medical professional during each simulation

SHEET NO.#

TECHNOLOGY & EQUIPMENT

Comments

START TIME -

TASKS

(with induction room)

ENVIRONMENT

Please mark observer location on plan

Falls

lt a e

SIMULATION - Pediatric | Laproscopic Hernia repair

OBSERVER -

Change in equipment positions for all scenarios

Trips

Setup Induction Procedure Emergence Breakdown

Furniture / equipment conflicts

Identify work system components during 5 phases based on SEIPS framework during each procedure

PERSON

Slips

SYSTEMS OBSERVATION

g n ti s e PATH OF TRAVEL & FD OBSERVATION SHEET T & n g i s e D s e i t i l i c a F h r

2 3 4

PROCEDURE

INDUCTION ROOM

EMERGENCE

6 7 8

BREAKDOWN

Please mark change in table position on plan Please mark change in primary equipment on plan Please mark change in location of trash can Please mark path of travel for your designated role throughout the simulation

Systems observation | December 2018

Please mark the location of observed SFDs with a circle and its annotated number

9 10

Please select what type of SFD and add any additional comments

Note-taking protocol for simulations | December 2018

MOCK-UP EVALUATION phase 6 POST-ENACTMENT SURVEY 1

Provide objective assessment of how well the OR mock-up supports overall flow of people and equipment

e.g. Reduce disruptions

lt a e

e t n e C

H r o f r

Provide insight into how well the OR mock-up supports overall flow of people and equipment

Solidify the placement of storage, equipment, and workstations

e D s

e i t i l i c a F h

Solidify the placement of storage, equipment, and workstations

e.g. Improve workplace ergonomics

& n g i s

POST-ENACTMENT FOCUS GROUP

g n ti s Te

POST-ENACTMENT VISUAL AWARENESS INTERVIEW 1

Provide insight into the impact of the wall-mounted displays on surgical team membersâ&#x20AC;&#x2122; work practices

& n g i s

DEBRIEFING QUESTIONS 1

g n ti s Te

Identify further system components that may be needed in the new OR to support the surgical team members work practices

e i t i l i c a F h

e D s

lt a e

H r o f r

e t n e C

PHASE 6 SYSTEMS EVALUATION STRATEGY

g n ti s Te

EBD GOAL

METRIC

TOOL

IMPROVE MOVEMENT & FLOW

Number of infractions into the sterile zone Number of infractions into the anesthesia zone Point of congestion (crowding) Ease of access to breakdown room Ease of access to wall outlets Ease of access to small mobile OR equipment Ease of access to surgeon workstation Availability of space for personal belongings Ease of transition of patient from induction room to OR Ease of transition of patient from gurney to surgical table Ease of access to printer (for MUSC) Ease of access to supplies

Observation of path of travel Observation of path of travel Observation of path of travel/Focus group Observation of path of travel Focus group/Outlet exercise Focus group Focus group Focus group Observation of path of travel/Focus group Observation of path of travel/Focus group Observation of path of travel/Focus group Focus group/Supplies exercise

IMPROVE VISUAL & INFORMATION AWARENESS

Movability/placement of CN workstation Location of wall mounted screens Height of wall mounted screens Content display of wall mounted screens

Observation of path of travel/Focus group Interview Interview Survey

REDUCE DISRUPTIONS IN THE OR

Number of bumps Number of slips Number of trips Number of falls Number of infractions with wires Path conflicts with furniture/equipment Change in route in response to obstacle Change in posture in response to cluttered pathway Change in posture in response to impeded view Number of times excessive reach is used

Observation of FD's Observation of FD's Observation of FD's Observation of FD's Observation of FD's Observation of FD's Observation of FD's Observation of FD's Observation of FD's Observation of FD's

REDUCE CONTAMINATION IN THE OR

Number of infractions into the sterile zone OR clean ability EVS

Observation of path of travel Interview

IMPROVE WORKPLACE ERGONOMICS

Ease of workstation mobility Height of wall mounted screens

Focus group Interview

& n g i s

e D s

alt

e H r o rf

e t n e C

e i t i l i c a F h

PEDIATRIC

OPTION A: OR with 1 door

g n ti s Te

OPTION B: OR with induction room

& n g i s

e D s

e i t i l i c a F h

ENT - Ear tubes and tonsilectomy

ORTHOPEDIC

alt

OPTION A: OR with 1 door

e H r o rf

Laparoscopic hernia repair ENT - Ear tubes and tonsilectomy

OPTION C: OR with breakdown room

e t n e C

Arthroscopic repair

ORTHOPEDIC-OPTION A: ARTHROSCOPY WITHOUT BREAKDOWN ROOM

g n ti s Te

INDIVIDUAL SIMULATION PATHS ANESTHESIOLOGIST 1

ANESTHESIOLOGIST 2

CIRCULATING NURSE

SURGEON

& n g i s

e D s

PRE-OPERATIVE PHASE 0-10 Minutes

PRE-OPERATIVE/ INTRA-OPERATIVE PHASE

e i t i l i c a F h

lt a e

10-20 Minutes

H r o f r

e t n e C

SCRUB NURSE

INTRA-OPERATIVE PHASE

Notetakers

Path of Travel

Equipment Primary location

Simulated storage

Circulating Nurse

Intermediate location

Anesthesiologist 1

Initial location

Simulated surgeons workstation

Surgeon

Ceiling mounted equipment Vision Cart

Anesthesiologist 2

Tape on the floor walls

Scrub Nurse

Surgeon Circulating Nurse

Patient

Anesthesia Cart

Surgeon Console

Anesthesiologist

Scrub Tech

20-30 Minutes

Robotic Equipment

COMPILED SIMULATION PATH AND FDs Pre-Operative Phase 0-10 Minutes

Intra-Operative Phase 10-20 Minutes

g n ti s Te

Intra-Operative / Post-Operative Phase 20-30 Minutes

& n g i s

e D s

e i t i l i c a F h

lt a e

H r o f r

e t n e C

FINAL DESIGN The shape and size of the OR prototype provides ample space to minimize conflicts in movement patterns, while minimizing unnecessary travel within the OR.

e D s

BREAKDOWN

The OR table is located off-center and at an angle in the room to accommodate surgical procedures on either side of the table and provides greater space for circulation during the procedure.

e i t i l i c a F h

lt a e

Windows The provision of windows in the OR with controls for glare, light, and privacy provides access to daylight and views to the outdoors to support improved satisfaction and reduced anxiety for patients and staff.

14' - 3" 14' - 3"

H r o f r

e t n e C

Zone distribution

The prototype is organized into clearly defined anesthesia, circulation, and sterile zones to improve the flow of staff and equipment outside the sterile zone, while maintaining sterility.

Digital information displays

The digital information displays are placed in multiple locations around the OR prototype to accommodate increased access to critical information for all surgical staff regardless of the position and orientation of the OR table and their associated viewing position. Door openings

6â&#x20AC;&#x2122; C GB&A

26' -- 0" 0" 26'

14' - 3" 14' - 3"

O.R. 579 SF

The basic room chassis can be integrated into a single corridor, clean core, or work core configuration and accommodate a variety of ancillary spaces such as an induction, instrument processing, or image control rooms.

& n g i s

Without WithInduction Breakdown

22' 22' -- 0" 0"

Angled OR table

g n ti s Te

Flexible room/ suite chasis

OR shape and size

The doors are located adjacent to the primary circulation zone to direct circulation away from the sterile and anesthesia zones and help reduce microbial load near the sterile zone. CN workstation The provision of a mobile workstation for the circulating nurse allows for flexibility in positioning the workstation to maximize views to the sterile zone and surgical team, and accommodated easy access to supplies.

& n g i s

g n ti s Te

e D s

e i t i l i c a F h

lt a e

H r o f r

e t n e C

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

03 1 2

PSLL studies

e D s

Circulating nurse work patterns and flow disruptions pg.43-44

e i t i l i c a 4h F alt 3

& n g i s

Door opening behaviors and patterns in the OR

pg.41-42

g n ti s Te

Contribution of minor flow disruptions to major events in the OR

pg.45-46

Factors impacting microbial loads in the OR

e t n e C

e H r o rf

pg.47-48

Are 3D gestural interfaces for anesthesia tasks intuitive?

Impact of layout on tasks performed in anesthesia workspace

Simulation modeling to evaluate an ideal OR layout

pg.49-50

pg.51-52

pg.53-54

Door opening behaviors and patterns in the OR

g n ti s Te

SNAPSHOT...

Why is it important?

The aim of this observational study was to understand the functionality and movement patterns of equipment and staff that contribute to door openings. Investigation in the OR revealed that the purpose of door opening, role of personnel involved, the duration and frequency of door openings, and location of the door were factors that could have implications on operations, as well as the design of OR physical environment.

Door openings have been shown to increase bacterial counts in the operating room (OR) as a result of air exchange between the OR and adjacent spaces, potentially increasing risks for Surgical Site Infections (SSIs). While the relationship between increased bacterial level and higher SSI risk in the OR and door motion attributes like frequency and duration of door opening as well as traffic patterns have been studied rigorously in the past, the factors associated with door opening itself have been minimally examined. This study characterized door motion attributes and traffic patterns in the OR to understand the factors that contribute to door openings from an operational (role and behavior of personnel) and environmental (location and type of door) perspective.

Safe OR design tool Desired outcome Reduce disruptions

H r o f r

Reduce bacterial load

Design strategy

Locate doors adjacent, or in direct access, to primary circulation area to direct flow away from the sterile and anesthesia zones

e t n e C

Provide doors with mechanisms that control the duration of door openings

An observational videography method was adopted to study the OR door openings. A convenience sample of 28 surgeries performed in three different ORs were video recorded and analyzed using the Noldus ObserverÂŽ XT (version 12.5) software.

lt 02 a e

Improve movement and flow

e D s

e i t i l i c a F h

What we did?

& n g i s

Types of doors corridor door clean door

28 Surgeries 15 general 03 orthopedic 10 pediatric

1527 Total door openings

What we found?

Purpose take out or bring in equipment, instruments or other items for patient transport/transfer as a shortcut shift changes talking, observing

Role

Duration

23.5%

5-27 secs

c a F h

Frequency

of the times doors remained open without use

Location

25%

In of the door opening events, the surgical table was the immediate destination

lt a e

H r o f r

Takeaways

s e i ilit

was the range of duration of door openings

instances of door openings were due to external personnel

& n g i s 40% e D

g n ti s Te

Door openings are a complex phenomenon and may impact operational and design decisions. Doors were commonly used by unknown personnel who were not a member of the surgical team to provide supplies or for having conversations related or unrelated to the surgery. There was a significant gap between the hold-open duration, and the time spent by the user to pass through the door. The surgical table was an immediate destination for numerous door opening events. Air patterns created by the traffic leading to the surgical table could introduce higher risks of pathogen transmission to the ultraclean zone. The detailed analysis of factors that contribute to door openings can help designers achieve desired safety outcomes in the OR.

e t n e C

Mousavi, E., Jafarifiroozabadi, R., Bayramzadeh, S., Joseph, A., & San, D. (2018, October 15). An observational study of door motion in operating rooms. Building and Environment, 144: 502-507. https://doi.org/10.1016/j.buildenv.2018.08.052

Circulating nurse work patterns and flow disruptions

g n ti s Te

SNAPSHOT...

Why is it important?

Utilizing prerecorded videos of surgeries conducted across three different ORs, this study explores how the layout configuration and adjacencies of functionally different zones within the OR can influence movement patterns of the circulating nurse and disruptions to their workflow.

The circulating nurse (CN) has the responsibility of observing, monitoring and managing potential threats during surgical procedures, at and around the surgical field. This requires their constant movement to different zones of the OR to support team members. The layout of the OR, as well as a crowded and cluttered environment, may contribute to unnecessary movement or create barriers to movement inside the OR resulting in workflow disruptions.

Safe OR design tool

Video recordings of 25 surgeries in 3 ORs were coded using the following categorizations

Desired outcome

i c a F h

Improve movement and flow Reduce disruptions

Design strategy

lt a e

H r o f r

Locate the circulation zone to support entry and exit into the OR without encroaching on anesthesia and sterile zones

e t n e C

e D s

What we did? Staff activities

il tie

P atient-related tasks E quipment-related tasks M aterial and supply-related tasks S taff I nformation-related tasks

OR 1

& n g i s

Staff location Surgical table zone 1 Surgical table zone 2 Supply zones Door zones Anesthesia zone CN Workstation zone Transitional zones (1&2)

OR 2

Type of FD Layout Environmental hazards

OR 3

What we found?

equen

Frequency of visit to each zone and distribution of FD across zones

Frequency of CN activities & duration of each activity P E M I

& n g i s 26%

432

Activity

2200 total FD’s

dis tr

ity

equen

of FD acro ss tion u z b i

es on

ion of each ac tiv rat u d

Frequency 07% 23% 35% 36%

Takeaways

Duration in hours (%)

Location

ies

Distribution of FD

t i l i c a F h

04 hr (13%) 06 hr (18%) 06 hr (18%) 18 hr (52%)

lt a e

H r o f r

Frequency 08% 05% 03% 32% 25% 10%

28%

6.3% 4.1% 58.3% 3.4%

involved CN

Layout

g n ti s Te 152

Environmental hazard

Types of FDs

Layout

Environmental hazards

adapt to inadequate space impeded visibility positioning of connectors, equipment, furniture and fixed structures in the OR

slipping, falling, tripping; interacting with sharp objects and contaminated needles; colliding with staff, equipment or furniture; excessively reaching to access patient, objects or equipment

CN’s movement patterns, to a large degree, required crossing through multiple zones. The CN’s workstation acted as a main hub from which the CN made frequent trips to both sides of the surgical table, the foot of the OR table, supply zones, and support zones. The circulating nurse experiences most of the flow disruptions in transitional zones. Locating frequently traveled zones closer or where possible adjacent may reduce the involvement of the CN in an SFD while performing an activity.

e t n e C

Bayramzadeh, S., Joseph, A., San, D., Khoshkenar, A., Taaffe, K., Jafarifiroozabadi, R., Neyens, D. M., & RIPCHD. OR Study Group. (2018, January). The Impact of Operating Room Layout on Circulating Nurse’s Work Patterns and Flow Disruptions: A Behavioral Mapping Study. HERD: Health Environments Research & Design Journal. DOI:https://doi. org/10.1177%2F1937586717751124 Neyens, D.M., Bayramzadeh, S., K. Catchpole, A. Joseph, K. Taaffe, K. Jurewicz, A. Khoshkenar, D. San & RIPCHD.OR Study Group (2018) Using a systems approach to evaluate a circulating nurse's work patterns and workflow disruptions. Applied Ergonomics. doi: 10.1016/j.apergo.2018.03.017

Contribution of minor flow disruptions to major events in the OR

g n ti s Te

SNAPSHOT...

Why is it important?

Based on video recordings of 28 surgeries, this study investigated attributes of minor and major flow disruptions (FD) during surgery and the impact of people involved, tasks performed, as well as the location of FDs and other environmental characteristics of the OR that may contribute to these disruptions.

Disruptions in the natural flow of surgical procedures contribute to higher stress, higher perceived workload for surgical staff, increased surgery duration, surgical errors and increased patient mortality. Sources of flow disruption (FD) in the OR include equipment malfunction, door openings, case irrelevant conversations, loud noises and alarms, communication breakdowns, environmental clutter and constrained spaces. Studies in operating rooms show that minor disruptions, when grouped together, may contribute to major events. Though the impact of the OR built environment on minor or major disruptions and eventually patient safety has been acknowledged, it has rarely been studied as a source of FD in the OR.

Safe OR design tool Desired outcome

What we did ?

e t n e C

Staff location

Types of FD layout, environmental hazards , usability, interruption and equipment failure Severity of FD (Palmer et al., 2013; Parker et al., 2010) Minor FD

H r o f r

lt a e

Staff activities

Major FD

Reduce disruptions

Provide sufficient circulation area to accommodate the flow of all surgical team members, equipment, and supplies.

e i t i l i c a F h

e D s

Video recordings of 28 surgeries in 3 ORs were coded using the following categorizations

Improve movement and flow

Design strategy

& n g i s

1—no impact/minor disruption-no response; 2—momentary disruption (acknowledgment of disruption, no pause in task); 3—momentary distraction (short pause <10 s); 4—primary task interrupted (task cessation >10 s); 5—primary task disruption (secondary task engaged) 6—repeat task

What we found?

Staff activities during major FDs

21%

Patient

21%

Equipment tasks

31%

Material & supply

27%

Information

Takeaways

e H r o rf

alt

& n g i s

e D s

e i t i l i c a F h

30%

occurred due to interruptions such as non-essential staff entering the OR, spilling or dropping of equipment and searching activities because of missing items in the OR

minor FD’s

total FD’s

In 98% of major FDs, a surgical staff member(s) either was momentarily distracted or had a pause or interruption in her/his task. In 2% of the cases they engaged in secondary activity or repeated surgical task

74%

2504

26%

major FD’s

g n ti s Te 73% of minor FDs did not result in behavior change

more than 50%

30%

of all the FDs originated from

of minor FDs originated from

layout issues

30%

of those occur in the

environmental hazards

anesthesia zone

Minor flow disruptions that occurred while performing equipment-related activities were related to increases in major flow disruptions. An increase in minor disruptions in the transitional zone that connects the CN workstation zone with the foot of the surgical table was slightly related to an increase in the rate of major flow disruptions. The number of transitions between OR zones and the overall density or crowdedness in the OR significantly impacted the occurrence of any type of flow disruption. The findings from this study clearly indicate that room design and layout issues contribute to an escalation of FDs in the OR.

e t n e C

Joseph, A., Khoshkenar, A., Taaffe, K. Catchpole, K., Machry, H., & Bayramzadeh, S. (2018, August 29). Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Quality & Safety, 0:1-8. http://dx.doi.org/10.1136/bmjqs-2018-007957

Factors impacting microbial loads in the OR

g n ti s Te

SNAPSHOT...

Why is it important?

This study examined how the movement of patient, equipment, materials, staff , door openings, temperature and humidity affect microbial load in the OR. Analysis of air samples from various representative locations in the OR led to establishment of evidence-based operational and design guidelines.

In previous research, surgical site infections (SSIs) have been associated with patient safety outcomes. The OR team, the number of people, their movement in the OR, door openings, surgical practices, scrub attire, etc. are some of the external risk factors that can lead to the development of SSI. One potential contributing factor to increased risk of SSI is microbial contamination in the OR. However, the relationship between staff movement patterns and microbial load levels hasnâ&#x20AC;&#x2122;t been examined closely. This study aimed to identify factors influencing microbial load in the OR using hierarchical regression modeling.

PHASE 1

Safe OR design tool

alt

Design strategy

During planning phases, locate and clearly identify circulation, anesthesia and sterile zones according to surgical team members related tasks

e t n e C

PHASE 3

Data was analyzed using hierarchical regression modeling

Location of air samplers & settle plates A B C D E

near door 1, high traffic area near door 2, high traffic area transition location, high traffic area low traffic area near door 2, high traffic area

D B A

Door 2

e H r o rf

Reduce bacterial load

PHASE 2

27 surgeries were video recorded and analyzed using Noldus Observer XT (version 12.5) to determine high and low transit areas Data was collected in 4 ORs across 21 procedures using air samplers and settle plates placed at identified locations

Door 1

Improve movement and flow

e D s

e i t i l i c a F h

What we did ?

Desired outcome

& n g i s

E C

Traffic flow by all of the staff in OR1 during surgery 1

What we found?

* Though the NUMBER OF DOOR OPENINGS was not a significant factor, proximity to a door impacted bacterial counts.

Takeaways

NUMBER OF PEOPLE did not contribute significantly to the microbial load

Higher TRAFFIC AREAS in the OR have a higher microbial load than the lower traffic areas.

Analysis of the air sampling data did not demonstrate differences by LOCATION in the bacterial load.

& n g i s

TEMPERATURE and HUMIDITY were not significant

e i t i l i c a F h

e D s

g n ti s Te The study produced mixed findings for average microbial load for the orthopedic and pediatric PROCEDURES due to difference in nature of procedures.

H r o f r

lt a e

This study demonstrated that movement in the OR is correlated with microbial load. Higher-traffic areas in the OR have a higher microbial load than lower-traffic areas. Extensive traffic between the anesthesia area and the door, as well as circulating nurse movements around the room and through the door suggest that it is important to control the traffic in the OR and move it away from the surgical field. Establishing operational guidelines or developing OR layouts that focus on minimizing movement by incorporating desirable internal storage points and workstations can potentially reduce microbial load, thereby potentially reducing surgical site infection risk.

e t n e C

Taaffe, K., B. Lee, Y. Ferrand, L. Fredendall, D. San, C. Salgado, D. Shvorin, A. Khoshkenar, and S. Reeves. â&#x20AC;&#x153;The influence of traffic, area location, and other factors on operating room microbial load,â&#x20AC;? in review with Infection Control and Hospital Epidemiology.

Are 3D gestural interfaces for anesthesia tasks intuitive? Why is it important?

SNAPSHOT...

e i t i l i c a F h

In person and video observations were used to identify functions representative of typical tasks performed by anesthesia providers in the OR

Desired outcome

alt

Reduce risk of contamination

e H r o rf

Note: Further research will be needed before a definitive conclusion can be reached regarding the influence of 3D gestural interfaces on design to achieve the desired outcome

e t n e C

& n g i s

e D s

What we did ?

Safe OR design tool

Design strategy

g n ti s Te

3D, vision-based, gestural input systems can serve as a natural way to interact with computers and are potentially useful in sterile environments (e.g., ORs) to limit the spread of bacteria. Anesthesia providersâ&#x20AC;&#x2122; hands have been linked to bacterial transfer in the OR, but a gestural input system for anesthetic tasks has not been investigated. Moreover, there is lack of research investigating similarities or variations in different usersâ&#x20AC;&#x2122; gesture interaction. This research sought to compare the mappings of gestures to functions generated for domain experts and novices exposed to the same OR anesthesia context to identify a single intuitive set of gestures.

This study identified 10 typical tasks performed by anesthesia providers in the OR; mapped and compared performance of these tasks between domain experts (anesthesia providers) and novices (students) using gestural input technology. The intent was to identify the similarities or differences in the gestural vocabularies of the two groups.

1. Start the flow 2. Stop the flow 3. Increase the flow 4. Decrease the flow

5. Silence alarm 6. Acknowledge the message 7. Heart rate normal?

Tasks were conducted with 2 groups of participants: Novice Experts Digital clocks and 3D gestural camera were used to measure response time and to map intuitive gestures-function

8. Pulse oximeter normal? 9. Select heart rate 10. Cancel the message

Thumbs up

Five up

Swipe hand left

Swipe hand up

Swipe hand down

Push fingers

Rotate left

Rotate right

Push hand

Gestures mapped to anesthesia functions

g n ti s Te

NOVICE (non-medical students)

EXPERT (anesthesia providers)

Number of participants (n=46)

n=30

n=16

Total gestures analyzed from those recorded

852

Total unique gestures identified for each group

What we found?

Mean reaction times

5.90 secs

Gesture-function mappings

Takeaways

H r o f r

4.34 secs

Functions 1-5 were associated with different gestures for the novices and the experts. Domain expertise and contextual knowledge of the physical and technological components of the environment impacted gestures.

c a F h

lt a e

s e i ilit

& n g i s

438

Functions 6 through 10, that were general human interaction tasks like canceling, selecting, providing yes/no answers, and acknowledging resulted in the same gestures for both the novices and the experts.

Experts and novices differ in terms of intuitiveness of gestures. The novice users showed significantly longer reaction times as compared to expert group. Expert gesture vocabularies that differed revealed a relationship to physical components in the contextual environment. For example, the functions related to manipulating anesthesia gas, there were more rotational gestures, similar to how anesthesia providers currently perform this task in the OR. Hence, context and domain expertise is meaningful while creating gestural vocabularies.

e t n e C

Jurewicz, K. A., Neyens, D. M., Catchpole, K., & Reeves, S. T. (2018). Developing a 3D Gestural interface for anesthesia-related human-computer interaction tasks using both experts and novices. Human Factors, 18720818780544. https://doi.org/10.1177%2F0018720818780544 Jurewicz, K., & Neyens, D. M. (2017, September). Mapping 3D Gestural Inputs to Traditional Touchscreen Interface Designs within the Context of Anesthesiology. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 61, No. 1, pp. 696-700). Sage CA: Los Angeles, CA: SAGE

Impact of layout on tasks performed in anesthesia workspace Why is it important?

SNAPSHOT...

What we did ?

e i t i l i c a F h

Improve movement and flow

alt

Design strategy

e H r o rf

e t n e C

e D s

Task Analysis. Tasks were paired to explore the frequency and direction of task switching. Each task pair was plotted as a line connecting the locations of where the tasks were performed.

Desired outcome

Position EMR computer to facilitate integration of EMR tasks into anesthesia maintenance workflow

& n g i s

Video Analysis. Video data from 6 surgeries was first used to analyze the time spent on different tasks by anesthesia providers during the maintenance phase of anesthetic care.

Safe OR design tool

Position anesthesia equipment in the anesthesia zone to minimize the amount of time that the anesthesia provider has their back turned away from the patient and visual displays

g n ti s Te

The anesthesia workspace is a small area for anesthesia providers, often with cluttered work surfaces and several pieces of fixed and/or movable equipment like anesthesia machine, electronic medical record (EMR) computer, infusion pumps, and drug storage and preparation areas. Anesthesia providers frequently switch between tasks, which means that the spatial arrangement of different devices can be critical for maintaining monitoring and patient awareness.

An initial study aimed to identify the tasks associated with anesthesia maintenance and transitions between anesthesia tasks. Based on initial findings, a later study attempted to inform anesthesia workspace design by observing the relationship between task switching and physical layout to explore different hypothetical anesthesia workspace layouts.

For example, if the anesthesia provider performed a series of tasks such as “patient visual displays - EMR - patient”, then the task pairs would be “patient-visual displays”, ”visual-displays-EMR”, then “EMR-patient.”

Workspace Layout Assessment. Data from 6 surgeries were used to test theoretical configurations of different workspaces (layout A,B,C & D) to assess the relationship between anesthesia workspace layout and workflow.

Layout A (original layout)

Layout B

Layout C

Layout D

What we found? Task switching analysis Example of analysis for layout D based on data from surgery 2 & 3

Time spent on tasks (during maintenance phase)

Workspace Layout Assessment

& n g i s

8.2 %

7.0 % 4.7 %

Layout A

30 %

Layout B Surgery 2

26.6 %

Patient EMR Visual display tasks

Takeaways

c a F h

Retrieving supplies Infusion pumps Preparing supplies Non-medical tasks

H r o f r

lt a e

The anesthesia provider is facing the patient for about half of the duration of the maintenance phase

e D s

4.4 %

18.6 %

g n ti s Te

e i t i il

The anesthesia provider has to look away from the patient when preparing and retrieving supplies

Layout C

Layout C further improved the centering of tasks towards the patient

Layout D

Layout D allows for the anesthesia provider to continually monitor the patient and patient displays while interacting with the EMR computer

Surgery 3

Patient and EMR tasks consumed the Layout D theoretically improves the centering of tasks around the patient, and by highest proportions of surgery time reducing the time spent with their back to the patient, enables increased awareness, On average across all surgeries, a task when compared to the original layout and the other alternatives. switch occurs every 6.39 seconds.

e t n e C

Jurewicz, K., Neyens, D., Catchpole, K., Joseph, A., Reeves, S., Abernathy, J. (under review) Using anesthesia workflow to evaluate physical workspace design and layout Betza, S. M., Jurewicz, K. A., Neyens, D. M., Riggs, S. L., Abernathy, J. H., Reeves, S. T. (2016). Anesthesia maintenance and vigilance: Examining Task Switching. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (pp. 608â&#x20AC;&#x201C;612). Santa Monica, CA: Human Factors and Ergonomics Society.

Simulation modeling to evaluate an ideal OR layout

g n ti s Te

SNAPSHOT...

Why is it important?

This study uses a simulation modeling approach to analytically evaluate and compare alternative design layouts with regard to: 1. Surgical table orientation 2. OR size 3. OR shape

There is a pressing need to improve safety and efficiency in the operating room. Post-surgical adverse events such as surgical site infections and surgical flow disruption occur at a significant rate and may result in mortality. The objective of this study is to identify an ideal room design using risk and safety performance measures in a simulation model with the goal of improving the flow of staff members.

What we did ?

e i t i l i c a F 3 h

23 surgical procedures were video recorded and analyzed for surgical flow data to create a dataset

Desired outcome

PHASE 2

Reduce disruptions Improve movement and flow

e t n e C

Position OR table so it can accommodate multiple orientations and locations to maximize room utilization

A simulation-based modeling tool was developed in order to test OR prototypes using

alt

e H r o rf

Size the OR to accommodate all surgical team members and their associated tasks and equipment

e D s

PHASE 1

Safe OR design tool

Design strategy

& n g i s

metrics TNC TDT NTS

Total number of contacts as a measure of congestion Total distance traveled Number of transitions near the surgical area as a measure of infection risk and safety

5 and 7 subjects 2 different locations of mobile CN workstation - Wall - Foot of the table

DOOR 2

CIRCULATING NURSE WORK STATION ZONE

SURGICAL TABLE ZONE 1 (right side of patient or head of patient) SURGEON'S WORK STATION ZONE

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

SURGICAL TABLE ZONE 2 (left side of patient or head of patient) FOOT OF SURGICAL TABLE ZONE

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

ANESTHESIA WORK STATION ZONE

DOOR 1

SUPPLY ZONE 1

DOOR 1 SURGICAL TABLE ZONE 1 (right side of patient or head of patient) DOOR 2

SUPPLY ZONE 2

DOOR 2

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

TRANSITIONAL ZONE

ANESTHESIA WORK STATION ZONE DOOR 2

ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 1 TRANSITIONAL ZONE

SUPPLY ZONE 1

SUPPLY ZONE 2 ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 2

INSTRUMENT TABLE + CASE CART SUPPORT ZONE SUPPLY ZONE 1

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

MISCELLANEOUS SUPPORT ZONE

SUGGESTED STAFF LOCATION DURING TASKS

SUPPORT ZONE 2B. MediumMISCELLANEOUS OR (prototype size) - 1 door

SUGGESTED STAFF LOCATION TASKS ZONE INSTRUMENT TABLE + CASE DURING CART SUPPORT

What we found?

g n ti s Te CIRCULATING NURSE WORK STATION ZONE

SURGEON'S WORK STATION ZONE

SUGGESTED STAFF LOCATION DURING TASKS

2A. Smaller OR (72% from prototype OR size) - 1 door

CASE 1

LOCATION ZONE KEY:

SUGGESTED STAFF LOCATION DURING TASKS

Base prototype 1C. OR table angled (as it is now) - 1 door CASE 2 MISCELLANEOUS SUPPORT ZONE

OR table perpendicular to the longer wall - 1 door

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

TRANSITIONAL ZONE DOOR 1

MISCELLANEOUS SUPPLY ZONE 2SUPPORT ZONE

1B.

TRANSITIONAL ZONE

FOOT OF SURGICAL TABLE ZONE

CASE 3

LOCATION ZONE KEY:

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

LOCATION ZONE KEY:

CIRCULATING NURSE WORK STATION ZONE

SURGICAL TABLE ZONE 2 (left side of patientNURSE or headWORK of patient) CIRCULATING STATION ZONE

CIRCULATING NURSE WORK STATION ZONE SURGEON'S WORK STATION ZONE

SURGEON'S WORK STATION ZONE

DOOR 1

SURGEON'S WORK STATION ZONE

FOOT OF SURGICAL ZONE SURGEON'S WORKTABLE STATION ZONE

FOOT OF SURGICAL TABLE ZONE

POSITION of the OR table

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

DOOR 1

TDT NTS

DOOR 2

3B. Rectangular OR (as prototype) / 1 door

TRANSITIONAL ZONE

DOOR 2

& n g i s

SURGEON'S WORK STATION ZONE

FOOT OF SURGICAL TABLE ZONE

SUPPLY ZONE 2

DOOR 1

Angled OR table SUGGESTED STAFF LOCATION DURING TASKS DOOR 2

TRANSITIONAL ZONE

2B. Medium OR (prototype size) - 1 door ANESTHESIA WORK STATION ZONE

SIZE of the OR

SUPPLY ZONE 2

TNC

Performed well in Case 3 & Case 2

FOOT OF SURGICAL TABLE ZONE MISCELLANEOUS SUPPORT ZONE

TDT

(diminishing benefit with increasing size)

FOOT OF SURGICAL TABLE ZONE SURGICAL TABLE ZONE 1

NTS

Performed best in Case 1 Performed best in Case 3

c a F h

Performed best in Case 3

TNC

alt

Performed best in Case 1

TDT NTS

Performed best in Case 2

r o rf

Takeaways

e t n e C

ies

ilit

421 sq ft

Square and small OR (20'x20') / 1 door

DOOR 1TABLE ZONE 2 SURGICAL (left side of patient or head of patient)

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

MISCELLANEOUS SUPPORT ZONE

SUGGESTED STAFF LOCATION DURING TASKS

2C. Larger OR (27% more than prototype OR size) TRANSITIONAL ZONE

1B.

LOCATION ZONE KEY:

ANESTHESIA WORK STATION ZONE

OR table perpendicular to the longer wall - 1 door

CIRCULATING NURSE WORK STATION ZONE SUPPLY ZONE 1

LOCATION ZONE KEY: CIRCULATING NURSE WORK STATION ZONE

LOCATION ZONE KEY: SURGEON'S WORK STATION ZONE

SURGEON'S WORK STATION ZONE SUPPLY ZONE 2

CIRCULATING NURSE WORK STATION ZONE FOOT OF SURGICAL TABLE ZONE

FOOT OF SURGICAL TABLE ZONE INSTRUMENT TABLE + CASE CART SUPPORT ZONE

SURGEON'S WORK STATION ZONE SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

SURGICAL TABLE ZONE 1 MISCELLANEOUS SUPPORT (right side of patient ZONE or head of patient)

SUGGESTED STAFForLOCATION DURING TASKS (right side of patient head of patient)

SURGICAL TABLE ZONE 1 2 SURGICAL TABLE ZONE (left side patient head patient) (right side of of patient or or head of of patient)

SUPPLY ZONE 2

DOOR 2

SURGEON'S WORK STATION ZONE INSTRUMENT TABLE + CASE CART SUPPORT ZONE

SURGEON'S WORK STATION ZONE

SUPPLY ZONE 1

SUPPLY ZONE 2 MISCELLANEOUS SUPPORT ZONE SURGICAL TABLE ZONE 1 (right side of patient or head of patient) INSTRUMENT TABLE + CASE CART SUPPORT ZONE SUGGESTED STAFF LOCATION DURING TASKS SURGICAL TABLE ZONE 2 (left side of patient or head of patient) MISCELLANEOUS SUPPORT ZONE

OR table perpendicular to shorter wall

LOCATION ZONE CIRCULATING NURSE KEY: WORK STATION ZONE CIRCULATING NURSE WORK STATION ZONE

ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 1 INSTRUMENT TABLE + CASE CART SUPPORT ZONE FOOT OF SURGICAL TABLE ZONE

DOOR 1

De SUPPLY ZONE 1 LOCATION ZONE KEY:

SUGGESTED STAFF LOCATION DURING TASKS

ANESTHESIA WORK STATION ZONE

SURGICAL TABLE ZONE 1 (right side of patient or head of patient) INSTRUMENT TABLE + CASE CART SUPPORT ZONE SURGICAL TABLE ZONE 2 (left side of patient or head of patient) MISCELLANEOUS SUPPORT ZONE

MISCELLANEOUS SUPPORT ZONE TRANSITIONAL ZONE

SUPPLY ZONE 1 CIRCULATING NURSE WORK STATION ZONE SUPPLY ZONE 2 SURGEON'S WORK STATION ZONE

SUPPLY ZONE 1

DOOR 2 INSTRUMENT TABLE + CASE CART SUPPORT ZONE

ANESTHESIA WORK STATION ZONE

LOCATION TRANSITIONAL ZONE KEY: ZONE

CIRCULATING NURSE WORK STATION ZONE ANESTHESIA WORK STATION ZONE

1C. OR table angled (as it is now) - 1 door

SURGICAL TABLE ZONE 2

SUPPLY ZONE 2

TRANSITIONAL ZONE

3A. Square OR (24'x24') / 1 door LOCATION ZONE KEY:

SUPPLY 1 or head of patient) (left sideZONE of patient

DOOR 1

OR table perpendicular to longer wall

SURGICAL TABLE ZONE 1

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

DOOR 2

2A. Smaller OR (72% from prototype OR size) - 1 door

SHAPE of the OR

ANESTHESIA WORKor STATION ZONE (right side of patient head of patient)

DOOR 1

No clear patterns were observed in terms of performance metrics though the TNC appear to be fewest in CASE 1

FOOT OF SURGICAL TABLE ZONE

TRANSITIONAL ZONE

SURGICAL TABLE ZONE 2 SURGICAL TABLE ZONEof1patient) (left side of patient or head

(right side of patient or head of patient)

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

TNC

DOOR 2

SURGICAL ZONETABLE 1 FOOT OFTABLE SURGICAL ZONE (right side of patient or head of patient)

FOOT OF SURGICAL TABLE ZONE SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

SURGICAL TABLE ZONE 2 SUGGESTED DURING TASKS (leftSTAFF side of LOCATION patient or head of patient)

SURGICAL TABLE ZONE 1

DOOR 1 of patient or head of patient) (right side

DOOR 1

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

DOOR 2

DOOR 1

DOOR 1 TRANSITIONAL ZONE TRANSITIONAL ZONE

TRANSITIONAL ZONE

DOOR 2

ANESTHESIA WORK STATION ZONE DOOR 2

ANESTHESIA WORK STATION ZONE

TRANSITIONAL ZONE

SUPPLY ZONE 1 ZONE TRANSITIONAL

SUPPLY ZONE 1

SUPPLY ZONE 2

ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 2

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

SUPPLY ZONE 1

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

MISCELLANEOUS SUPPORT ZONE

SUPPLY ZONE 2

MISCELLANEOUS SUPPORT ZONE

580 sq ft

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

3B. Rectangular OR (as prototype) / 1 door SUGGESTED STAFF LOCATION DURING TASKS

739 sq ft

SUGGESTED STAFF LOCATION DURING TASKS

MISCELLANEOUS SUPPORT ZONE

LOCATION ZONE KEY:

LOCATION ZONESUGGESTED KEY: STAFF LOCATION DURING TASKS

SURGEON'S WORK STATION ZONE

FOOT OF SURGICAL TABLE ZONE

1C. OR table angled (as it is now) - 1 door SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

2C. Larger OR (27% more than prototype OR size)

SURGEON'S WORK STATION ZONE SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

DOOR 2

CIRCULATING NURSE WORK STATION ZONE

FOOT OF SURGICAL TABLE ZONE ANESTHESIA WORK STATION ZONE

ANESTHESIA WORK STATION ZONE FOOT OF SURGICAL TABLE ZONE

ANESTHESIA WORK STATION ZONE

SURGICAL TABLE ZONE 1 SUPPLY (right side of ZONE patient 1or head of patient)

SUPPLY ZONE 1 SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

DOOR 2

SUPPLY ZONE 1

SURGICAL TABLE ZONE 2 ZONEor2 head of patient) (leftSUPPLY side of patient

SUPPLY ZONE 2 SURGICAL TABLE ZONE 2

TRANSITIONAL ZONE

DOOR 1 INSTRUMENT TABLE + CASE CART SUPPORT ZONE

(left side of patient or head of patient)

SUPPLY ZONE 2

INSTRUMENT TABLE DOOR 1 + CASE CART SUPPORT ZONE

ANESTHESIA WORK STATION ZONE

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

DOOR 2 MISCELLANEOUS SUPPORT ZONE

Square

MISCELLANEOUS DOOR 2SUPPORT ZONE

SUPPLY ZONE 1

Rectangular

TRANSITIONAL SUGGESTEDZONE STAFF LOCATION DURING TASKS

TRANSITIONAL ZONE DURING TASKS SUGGESTED STAFF LOCATION

SUPPLY ZONE 2

(20’ X20’)

DOOR 2

SURGEON'S WORK STATION ZONE TRANSITIONAL ZONE

TRANSITIONAL ZONE SURGEON'S WORK STATION ZONE

DOOR 1

Square & small

CIRCULATING NURSE WORK STATION ZONE

LOCATION ZONE KEY:

DOOR 1

MISCELLANEOUS SUPPORT ZONE

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

LOCATION ZONE KEY: DOOR 1

DOOR 1

FOOT OF SURGICAL TABLE ZONE

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

CIRCULATING NURSE WORK STATION ZONE SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

CIRCULATING NURSE WORK STATION ZONE

SUGGESTED STAFF LOCATION DURING TASKS

FOOT OF SURGICAL TABLE ZONE

LOCATION ZONE KEY:

FOOT OF SURGICAL TABLE ZONE

TRANSITIONAL ZONE

MISCELLANEOUS SUPPORT ZONE

SURGEON'S WORK STATION ZONE

DOOR 2

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

LOCATION ZONE KEY:

CIRCULATING NURSE WORK STATION ZONE

2B. Medium OR (prototype size) - 1 door

SUPPLY ZONE 2 SUGGESTED STAFF LOCATION DURING TASKS

3A. Square OR (24'x24') / 1 door

ANESTHESIA WORK STATION ZONE

(24’ X24’)

SUGGESTED STAFF LOCATION DURING TASKS INSTRUMENT TABLE + CASE CART SUPPORT ZONE

ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 1

MISCELLANEOUS SUPPORT ZONE

SUPPLY ZONE 2 SUPPLY ZONE 2

SUGGESTED STAFF LOCATION DURING TASKS

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

MISCELLANEOUS SUPPORT ZONE

SUGGESTED STAFF LOCATION DURING TASKS

As number of people in the OR increased, all outcomes deteriorated. Though distance walked was less when the CN workstation was closer to the OR table, number of transitions near surgical area were found to be higher. Distance walked was least in the small ORs though number of contacts and transitions near surgical area were higher. Diminishing returns of increasing area were observed on NTS and TNC. Overall, the prototype appeared to be effective for the measures tested. 3B. Rectangular OR (as prototype) / 1 door

2C. Larger OR (27% more than prototype OR size)

LOCATION ZONE KEY:

Square and small OR (20'x20') / 1 door

CIRCULATING NURSE WORK STATION ZONE

LOCATION ZONE KEY:

CIRCULATING NURSE WORK STATION ZONE

LOCATION ZONE KEY:

SURGEON'S WORK STATION ZONE

CIRCULATING NURSE WORK STATION ZONE

FOOT OF SURGICAL TABLE ZONE

SURGEON'S WORK STATION ZONE

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

FOOT OF SURGICAL TABLE ZONE

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 1

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

SURGICAL TABLE ZONE 1 (right side of patient or head of patient)

DOOR 1

SURGICAL TABLE ZONE 2 (left side of patient or head of patient)

DOOR 2

DOOR 1

TRANSITIONAL ZONE

DOOR 2

ANESTHESIA WORK STATION ZONE

TRANSITIONAL ZONE

Taaffe, K.,Joseph, A., Khoshkenar, A., Machry, H., Allison, D., Reeves, Scott, R. (under review) Proactive Design of a Safe and Efficient Operating Room: A Simulation-Based Modeling Approach

SUPPLY ZONE 1

ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 1

SUPPLY ZONE 2

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

MISCELLANEOUS SUPPORT ZONE

SUGGESTED STAFF LOCATION DURING TASKS

ANESTHESIA WORK STATION ZONE

SUPPLY ZONE 2

SUPPLY ZONE 1

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

SUPPLY ZONE 2

MISCELLANEOUS SUPPORT ZONE

INSTRUMENT TABLE + CASE CART SUPPORT ZONE

SUGGESTED STAFF LOCATION DURING TASKS

MISCELLANEOUS SUPPORT ZONE

SUGGESTED STAFF LOCATION DURING TASKS

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

Methods toolkit

& n g i s

g n ti s Te

Several methods were employed during the multi-phase research project to formulate research questions, conduct observations, identify systems bottlenecks, evaluate multiple facets of design, and address research challenges during the four-year learning lab. This section provides an overview of some of the methods used by the research team at various phases of the project. Practical and useful tools ranging from video observations and mock-up evaluations to computer simulation technologies were developed by the team. These tools are intended to support researchers and designers in gathering data in line with the design goals of their project, and guiding the design and development process. Each of the methods in this section can be leveraged at different times in the iterative research and design process to support an evidence-based approach. Some of the methods may be used as stand-alone tools, while others in combination, based on the requirement of the project. The culmination of these efforts has resulted in the â&#x20AC;&#x153;Safe OR Design Tool,â&#x20AC;? which is a web-based tool that can be utilized by multiple stakeholders to understand how design can impact safety in the OR.

e D s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

OVERVIEW OF THE METHODS TOOLKIT

Video Observation Tool

Flows Mapping tool

& n g i s

e D s

HOW TO GET STARTED?

e i t i l i HOW TO ASSESS IF YOUR c a SOLUTION IS WORKING? F h t l a e HOW TO MAKE MY CONCEPT REAL? H r o r f HOW TO TURN FINDINGS INTO AN Low-Medium Fidelity Mock-up Evaluation High Fidelity Mock-up Evaluation

Capacity Analysis Modeling

e t n e C

Task Switching Analysis

OR Flow Modeling Tool

OPPORTUNITY FOR DESIGN?

Safe OR Design Tool

g n ti s Te

VIDEO OBSERVATION TOOL

The Video Observation Tool supports researchers in conducting and analyzing video observations using a systems approach.

TASK SWITCHING ANALYSIS

Task Switching Analysis is a simple methodology that allows for quick assessment of the impact of workspace design on anesthesia providers workflow.

LOW-MEDIUM FIDELITY MOCK-UP EVALUATION

The Low/Medium-fidelity Mock-up Evaluation Tool supports multidisciplinary design teams in conducting scenario-based simulation evaluations within a low/medium-fidelity physical mock-up.

HIGH FIDELITY MOCK-UP EVALUATION

The High-fidelity Mock-up Evaluation Tool supports multidisciplinary design teams in conducting systems-based simulation evaluations within a high-fidelity physical mock-up.

& n g i s

e D s

e i t i l i c a F h

lt a e

H r o f r

OR FLOW MODELING TOOL

The OR Flow Modeling Tool is an analytical simulation tool used to evaluate operating room designs that improve workflow metrics.

CAPACITY ANALYSIS MODELING

The Capacity Analysis Modeling Tool is an analytical simulation tool used to determine the capacity and operations of a designed space using retrospective data.

SAFE OR DESIGN TOOL

The Safe OR Design Tool supports clinicians, designers, and researchers in better understanding how to design a safer more ergonomic OR.

e t n e C

pg.65-66 pg.63-64

The Flows Mapping Tool informs design decision making by identifying strategic spatial configuration characteristics of facilities through case study tours.

pg.67-68

FLOWS MAPPING TOOL

pg.71-72 pg.69-70

Description

pg.73-76

TOOL

pg.61-62 pg.59-60

g n ti s Te

FLOWS MAPPING TOOL

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

Case study tours are important for healthcare design teams and clients to learn about the impact of design on the surgical process. However, these tours are often unstructured and rarely document the information obtained to allow meaningful conclusions or comparisons between facilities. Recognizing the challenges associated with effectively understanding how design can best support the flow of objects, people and information within complex surgical processes, the RIPCHD. OR research team developed a flow mapping tool to structure documentation and analysis of information gathered during case study tours at multiple surgery centers. The Flows Mapping Tool guides graphic documentation, observation, and staff inquiry during the short time frame allotted for a typical facility tour, enabling a process-based spatial evaluation for comparing case studies and informing design decision-making.

The Flow Mapping Tool can be integrated in the design process by different team members working on healthcare facility projects, such as architects and researchers within architecture firms. This tool can be used by both novice and expert design researchers to provide meaningful data to guide the conceptual and programmatic phases of the design process.

H r o f r

e D s

WHY USE THE TOOL?

This tool provides a step-by-step guide for healthcare design teams to work during fast-paced facility tours, helping them document, describe and compare design solutions across different healthcare facilities in a more efficient and effective way. As such, this tool can be used to inform healthcare design decision-making, helping designers and researchers understand how and why varying spatial configuration characteristics are working as facilitators or barriers to the efficiency of healthcare flows and services in different healthcare facilities. Furthermore, the tool can serve as base to identify critical flows and apply the same evaluation approach in other types of healthcare settings.

e i t i l i c a F h

lt a e

& n g i s

e t n e C

PROBLEM ANALYSIS

DESIGN

DEVELOPMENT

IMPLEMENTATION

EVALUATION

2. DOCUMENTING FLOWS (during site tour) B.

PHYSICAL ASSESSMENT OF FLOWS

[ADD FLOOR PLAN] 2. DOCUMENTING FLOWS (during site tour) WHAT’S IN THE TOOL?

[ADD FLOOR PLAN]

DOCUMENTING SPATIAL CONTEXT (prior to site tour)

Documenting context is critical to understanding facility wide factors influencing the flows of people and objects moving across surgical environments. a. Pre-assessment questionnaire b. Physical assessment checklist

Documenting how the flows of people and objects are moving through the surgical environment is critical to understanding how spatial configuration supports the surgical process. Critically examining the pathway of these flows requires a human-centered approach, which is ideally constructed by overlapping the perspectives of multiple users. a. Interview questions (audio-recording and note-taking) b. Physical assessment of flows c. Photo assessment

lt a e

e i t i l i c a F h

PROCESS BASED SPATIAL EVALUATION (following site tour)

Once the physical progression of each flow is graphically identified on the floor plan, it is critical to evaluate how the spatial characteristics of the pathways and spaces impact the surgical process. Identifying and evaluating spatial facilitators (spaces that support one or multiple flows) and barriers (spaces that hinder one or multiple flows) is critical to identifying points of strength and weakness in the design of the facility and informing a more evidence-based approach to design decision-making. a. Identifying spaces associated with essential and non-essential steps b. Identifying spatial facilitators and barriers c. Analyzing spatial facilitators and barriers

H r o f r

& n g i s

e D s

DOCUMENTING FLOWS (during site tour)

e t n e C

g n ti s Te

PHYSICAL ASSESSMENT FLOWS B. PHYSICAL ASSESSMENT OFOF FLOWS

Check ( ) once marked on the floor plan Record the color code for each flow CHECK

COLOR CODE

CHECK

TYPICAL PATHWAY OF

PA patient flow ( ) FA family flow ( ) SG surgeon flow ( ) AN anesthesiology team flow ( ) SI sterile instruments and materials flow ( ) Check ( ) once marked on the floor plan ME movable equipment flow ( ) SU supplies ( ) Record the color code for each flow WA waste ( CHECK) COLOR CODE TYPICAL PATHWAY OF

( ) ( ) ( ) ( ) ( ) ( ) ( ) ( CHECK)

FUNCTIONS OF ALL SPACES WITHIN PA patient flow FA family flow SG surgeon flow AN anesthesiology team flow SI sterile instruments and materials flow ME movable equipment flow SU supplies WA waste OF ALL SPACES WITHIN FUNCTIONS

3. PROCESS-BASED SPATIAL EVALUATION (following site tour)

patient flow family flow 07 surgeon flow AN anesthesiology team flow AN anesthesiology team flow ( ) ( ) SI sterile instruments and materials flow SI sterile instruments and materials flow 1 ( EXAMPLE ) ( ) ME movable equipment flow ME movable equipment flow ( Perceived ) ( ) impact type Facilitators Barriers SU supplies SU supplies ( (Mark)all that apply) ( ) WA waste WA waste ( Perceived ) ( ) • Minimized time: no patient transport time needed impact description between preoperative assessment and anesthetic induction • Minimized building footprint: no amenity spaces/areas 07 needed during preoperative assessment

(

)

patient flow

(

)

PA FA

FA family flow ( ) ( ) ANALYZING SPATIAL FACILITATORS AND BARRIERS SG SG surgeon flow ( ) ( )

Flow type impacted (Mark all that apply)

Patient flow

Sterile instruments and materials flow

Family flow

Movable equipment flow

Surgeon flow

Supplies

Anesthesiology team flow

Waste

Space type

Space dedicated to only one essential step

(Mark all that apply)

Space dividing essential steps in the flow Space combining multiple essential steps in the flow Space dedicated to non-essential steps

Spatial characteristic description

• •

Induction room adjacent to OR No amenity spaces/areas needed during preoperative assessment, such as patient toilets and staff workstations for patient surveillance

Proposed design response

•

Include induction rooms adjacent to ORs

(as relevant to the space condition as a facilitator or barrier)

EXAMPLE 2 Perceived impact type

Facilitators

(Mark all that apply)

Perceived impact description Flow type impacted

•

Barriers

Added time: unnecessary time spent waiting for the elevator Patient flow

Sterile instruments and materials flow Movable equipment flow

VIDEO OBSERVATION TOOL

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

When conducting observations in a complex and dynamic environment like the OR, it is crucial to utilize an observation method that allows for an in-depth, systematic way of accurately and reliably capturing multiple types of information at the same time, while not interfering or interrupting the natural flow of activities. The use of videography to conduct observations provides a unique opportunity for research teams to collect large amounts of data from an OR environment that allow for a deeper understanding of how different environmental factors impact surgical team membersâ&#x20AC;&#x2122; behaviors, task performance, and safety outcomes. Video observations also have the added benefit of not requiring observers to be in the environment to capture data, and supporting unlimited replay of multiple scenes to ensure information is captured in detail during the coding process. This tool provides a systematic approach for conducting video observations in OR environments, as well as for developing an in-depth coding scheme linking environmental and behavioral variables using a systems-based approach.

The Video Observation Tool was developed to engage a multidisciplinary research team comprised of design researchers, human factors engineers, industrial engineers, and operations management researchers in coding videos of surgical procedures in ORs of varying size and configuration. This tool can be especially useful for researchers in helping them develop a coding scheme to understand the impact of the physical environment on surgical team membersâ&#x20AC;&#x2122; observed behaviors.

e D s

e i t i l i c a F h

lt a e

H r o f r

WHY USE THE TOOL?

& n g i s

Multidisciplinary research teams will find this tool useful for supporting a systems-based approach to conducting video observations in surgical environments. Specifically, this tool provides a coding strategy that can capture momentary events and their associated behaviors in detail, and supports a more ecologically valid approach to conducting observations in surgical environments, as it does not rely on subjective memory-based feedback from subjects. Additionally, this tool facilitates an in-depth analysis of key variables of interest, allowing for analysis of parallel events across time and the spatial relationship between those events.

e t n e C

PROBLEM ANALYSIS

DESIGN

DEVELOPMENT

IMPLEMENTATION

EVALUATION

WHAT’S IN THE TOOL?

POSITIONING OF CAMERAS TO CAPTURE DATA

ZONE DEVELOPMENT GUIDE This document provides a reference for how to develop a systematic zoning scheme for an OR environment, and how to apply that scheme across varying OR layouts. The zone development guide has three main sections. a. Zone development and distribution b. Zone classification and their associated definitions c. Step-by-step guide for applying the zones across different OR environments

MASTER CODING PROTOCOL

lt a e

H r o f r

ANALYSIS GUIDE

BREAKDOWN

& n g i s

e D s

e i t i l i c a F h

This document provides an overall reference for the coding protocol that can be used by researchers to train multiple coders and support mounted on poles inter-rater reliability during the coding process.cameras The master coding base machine & computer screen protocol contains three main sections. a. Overview and step-by-step guide to the process connections - camera to computer ﬁeld of view Surgical b. Comprehensive list of all codes and their definitions: phases, Location, Subjects, Objects, PEMSI activities, Flow disruptions c. Prompts for potential challenges that can occur during the coding process and how to resolve those challenges

g n ti s Te

cameras mounted on poles

base machine & computer screen connections - camera to computer ﬁeld of view

VIDEO ANALYSIS USING OBSERVER XT

This document provides a reference for how to extract the data once all coding has been conducted and how to apply various analysis strategies to the data that allow for an in-depth understanding of interconnections between variables. The analysis guide has two main sections a. Overview and step-by-step guide for extracting and preparing time-based data for analysis b. Application of various analysis strategies to the data and examples for how to implement those strategies or multiple flows is critical to find points of strength and weakness in the design of the facility. Therefore, informing a more evidence-based approach to design decision-making.

e t n e C

TASK SWITCHING ANALYSIS

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

The RIPCHD.OR research team and other research studies have shown that the layout of anesthesia workspace does not necessarily fit the complexity of work performed in the OR. There are few evidence-based approaches that support the investigation of OR design strategies that account for the arrangement and integration of equipment and other technologies within the anesthesia workspace. The RIPCHD.OR research team developed an approach to study the relationship between anesthesia task switches and the anesthesia workspace layout, and to utilize this data to assess future hypothetical anesthesia workspace designs. Our approach consists of a detailed task analysis of anesthesia work and mapping task switches to the workspace layout to understand how the arrangement of equipment affects anesthesia providerâ&#x20AC;&#x2122;s task performance. Our approach is a simple methodology that allows for a quick assessment of layout design and is able to show how to better design workspaces to suit the flow of tasks and support patient care.

The Task Switching Tool can be used by a variety of people working on healthcare projects in the OR like engineers, healthcare researchers, architects, or anesthesia providers. Although the current work demonstrated a tool specific to the anesthesia workspace, the tool can be extended to other specialties. Video data should be captured and documented in order to complete the task analysis. The data is to be broken up into task categories second by second to provide a comprehensive picture of work demands. Researchers should additionally conduct in-person observations to understand the work domain and to ensure that the task analysis is performed accurately.

lt a e

H r o f r

e t n e C

PROBLEM ANALYSIS

DESIGN

e D s

e i t i l i c a F h WHY USE THE TOOL?

& n g i s

The task switching tool is a quick way to analyze current workspace designs as well as understand how future designs or new integrated technologies impact the work flow. This tool is able to support decision making for workspace design, and it helps in understanding the effects of the arrangement of equipment on task switches. The tool specializes in understanding the relationship between physical environment, tasks, technologies and tools, and can be used in conjunction with other methodologies that assess organizational and personal factors. Every component of a work system tasks, tools and technologies, person, environment, and organization â&#x20AC;&#x201C; is interdependent, and changes to one component will impact the entire work system. Thus, it is important to have tools such as the task switching tool to test workspace designs preemptively to help designers avoid expensive errors.

DEVELOPMENT

IMPLEMENTATION

EVALUATION

WHATâ&#x20AC;&#x2122;S IN THE TOOL?

HORIZONTAL TASK TIMELINE PLOT

DEVELOPMENT OF TASK CATEGORIES To understand the complexity of work, tasks can be identified and defined based on video observations and previously published literature. a. Patient b. Visual displays c. EMR d. Retrieving supplies e. Preparing supplies f. Infusion Pumps g. Handoff h. Not in work space i. Non-medical task

e D s

e i t i l i c a F h

HORIZONTAL TASK TIMELINE PLOT

Based on the time spent on each activity identified and frequency of switching, the tasks can be plotted as a horizontal timeline plot to visualize the progression of tasks and how often they are switched.

& n g i s

g n ti s Te

TASK SWITCHING AND WORKSPACE ASSESSMENT

lt a e

TASK SWITCHING

The observed tasks can be broken down into pairs, which provide a stepby-step progression of workflow. The task pair data can then be plotted on a diagram of the anesthesia workspace layout as a line connecting the locations of where the tasks are performed. This figure will show a step-bystep progression of tasks, a visual representation of task switches, and the relationship between tasks and layout design.

H r o f r

e t n e C

ANESTHESIA WORKSPACE DESIGN ASSESSMENT Visualization of task analysis and task switching data superimposed on a layout diagram provides an understanding of how well the arrangement of equipment in the workspace supports task performance. Hypothetical layouts can also be assessed using this method too.

LOW-FIDELITY MOCK-UP EVALUATION

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

When designing an OR environment, it is critical to engage clinical end users in the design process to help identify design features within the built environment that could pose potential safety risks that may adversely impact patients and staff. Conducting scenario-based simulations in physical mock-ups provides a unique opportunity for multidisciplinary design teams to iteratively test how different design features may impact patient and staff safety. Physical mock-ups also have the added benefit of helping clinical end users visualize how different design options may impact critical processes prior to implementation in a live clinical setting. This tool provides a systematic approach to planning and conducting scenario-based simulations in a low/medium-fidelity physical mock-up, as well as collecting data from the simulations.

The Low/Medium-Fidelity Mock-up Evaluation Tool was developed to engage a multidisciplinary design team comprised of clinicians, designers, design researchers, and human factors experts in designing an OR prototype through multiple rounds of iterative scenario-based simulation testing. This tool can be especially useful for clinicians and designers in helping to test a range of design options and identify high performing design solutions.

e D s

e i t i l i c a F h

lt a e

H r o f r

WHY USE THE TOOL?

& n g i s

Multidisciplinary design teams will find the tool useful for supporting a systematic approach to conducting scenario-based simulations in a low/ medium-fidelity physical mock-up. Specifically, this tool provides protocols and evaluation tools for planning and conducting simulations, and collecting data to support an iterative design process. Additionally, the tool can be used to maximize engagement with clinical teams during the design process. This systematic approach to obtain evidence-based feedback from clinical endusers iteratively during the design process provides an opportunity to test a range of design options and validate design decisions in a low/mediumfidelity physical mock-up.

e t n e C

PROBLEM ANALYSIS

DESIGN

DEVELOPMENT

IMPLEMENTATION

EVALUATION

WHAT’S IN THE TOOL?

MASTER PROTOCOL Task/scenario Patient entry into room and transfer to surgical table

MASTER PROTOCOL The protocol provides an overall reference for the mock-up evaluation process that can be used by team members throughout the simulations to facilitate fluid transitions between simulations. The master protocol contains five main sections. a. Prebrief with evaluation objectives b. Scenario overview outlining simulated tasks c. Equipment and supplies list associated with each scenario d. Design features to be tested during each scenario e. Evaluation questions outline

SIMULATION DIRECTOR’S WORKSHEET

c a F h

r o rf

NOTETAKERS TEMPLATE

alt

The notetakers template aligns with the simulation director’s worksheet and provides a structured format for capturing observations during the simulations. It contains three main sections a. Floor plans for each design option tested b. Observation checklist for capturing participant feedback c. Debriefing questions with associated space for taking notes

e t n e C

& n g i s

e D s

e i t i il

This document provides a prompt for the simulation director to keep the simulation evaluations moving forward within the allotted timeframe. The simulation director’s worksheet contains four main sections. a. Overview and agenda of the evaluation process b. Description of scenarios and design features under evaluation c. Prompts for leading the scenarios and obtaining participant feedback during the simulations d. Debriefing questions associated with evaluation objectives

Pre-operative positioning of teams and equipment (based on procedure map) Preoperative tasks for different team members  Anes task related to accessing storage  Circulating nurse/scrub task related to accessing internal OR storage  Time out – look at large screen as a team to go through time out. Circulating nurse directs time out from her table? Transition from pre-operative positioning to intra-operative positioning of teams and equipment  Team members will orient themselves and the equipment to align with the different side of the surgical table  Teams simulate intra-operative position and tasks  Teams simulate specific tasks that may require them to view the large screen  Team simulate specific task that requires the anesthesiologist to access supplies, dispose trash Transition from intraoperative to postoperative positioning of teams and equipment  Scrub simulate disposal of trash  Circulator – epic documentation  Surgeon- epic documentation

g n ti s Te

Surgical table sidedness Access to anes storage Access to circulating nurse storage Number and location of large screens and monitors Type of information that would be useful to display

Surgical work station location Circulating nurse workstation Display screen needs

Patient is transferred from room  Room clean up  Team discussion re next patient

Door size Door location Surgical table sidedness

Door location Storage location

RIPCH.OR MOCKUP SCENARIOS PROTOCOL –December 2016 | 2

NOTETAKERS TEMPLATE PREOPERATIVE PHASE PREOPERATIVE PHASE

Task

Evaluation question

Bed transfer

Stretcher brought in

Anesthesia task related to accessing storage (TBD)

Are there any bumps or challenges maneuvering the gurney? Is there a clear path of movement from the door to the surgical table?

check Notes

Where is the ideal storage location for the anesthesia personnel? How much storage is needed for the anesthesia personnel?

Surgeon enters and reviews patient information at surgical workstation. Discusses surgery with team members

Time Out on large screen in the room

Is the circulating nurse able to lead the time out discussion from her station? Can all team members view the timeout screen?

Additional questions and notes:

RIPCH.OR MOCKUP SIMULATION SUMMARY –December 2016 | 2

HIGH-FIDELITY MOCK-UP EVALUATION

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

The OR environment supports dynamic interactions between surgical team members, the tasks required to support their work practices, the technology and equipment used to perform surgical procedures, organizational and operational protocols, and the built environment. Any change in one of these system components is likely to affect other components within the system. Physical mock-ups provide a unique opportunity to test environmental design features for potential safety concerns and to understand how the system components function together prior to implementation in a live clinical setting. Conducting simulations in physical mock-ups also has the added benefit of helping build consensus around proposed environmental design features by engaging multidisciplinary design teams in the design process. This tool provides a multi-layered data collection strategy that utilizes a systems approach for conducting and evaluating scenario-based simulations in a high-fidelity physical mockup.

The High-Fidelity Mock-up Evaluation Tool was developed to engage a multidisciplinary design team comprised of clinicians, designers, design researchers, and human factors experts in examining how well the system components holistically function within a high-fidelity physical mock-up of the RIPCHD.OR OR prototype during scenario-based simulation testing. This tool can be especially useful for helping clinical teams understand how different environmental design features can impact workflow patterns and for identifying associated flow disruptions (FDs) that can lead to potential safety concerns.

lt a e

H r o f r

e t n e C

PROBLEM ANALYSIS

DESIGN

e D s

e i t i l i c a F h WHY USE THE TOOL?

& n g i s

Multidisciplinary design teams will find the tool helpful for linking project specific evidence-based design (EBD) goals with metrics that can be evaluated in a high-fidelity mock-up during simulation testing. Specifically, this tool can be used to evaluate target outcomes such as FDs that can provide an objective measure for how well proposed design features support workflow patterns and identify potential system vulnerabilities that can impact patient and staff safety. Additionally, this tool can be used by clinical teams to prospectively identify necessary workflow changes prior to occupying a new environment. The multi-layered data collection strategy provides an opportunity to obtain both subjective insights from clinical end users, as well as objective measures for how well a simulated high-fidelity OR environment supports clinical end users workflow patterns.

DEVELOPMENT

IMPLEMENTATION

EVALUATION

PATH OF TRAVEL OBSERVATION SHEET

(with induction room)

ENVIRONMENTAL

Wire Infraction

Excessive Reach

Falls

Trips

Slips

Bumps

COMMENTS COMMENTS

The focus groups provide a platform for the surgical team to collectively discuss how well the high-fidelity OR mock-up supports the overall workflow of the team and identify workflow patterns that may need to be adjusted in response to proposed environmental design features to further support patient and staff safety.

7 8

Please mark change in table position on plan Please mark change in primary equipment on plan

Please mark change in location of trash can Please mark path of travel for your designated role throughout the simulation

Please mark the location of observed SFDs with a circle and its annotated number Please select what type of SFD and add any additional comments

Note-taking protocol for simulations | December 2018

SYSTEMS OBSERVATION SHEET OBSERVER Please mark observer location on plan

SIMULATION - Pediatric | Laproscopic Hernia repair

START TIME -

SHEET NO.#

(with induction room)

Comments

Work system based on SEIPS framework ORGANIZATION

TECHNOLOGY & EQUIPMENT

These interviews provide further insight into how well integrated visual information displays in the high-fidelity OR mock-up support individual surgical team member’s workflow patterns.

INDUCTION ROOM

TASKS

alt

VISUAL AWARENESS INTERVIEWS

ENVIRONMENT

c a F h

ies

ilit

The survey provides an objective assessment from individual surgical team members regarding how well the physical mock-up supports the overall flow of people and equipment, as well as solidify the placement of design features such as storage, equipment, and workstations.

PERSON

POST-ENACTMENT SURVEY

e t n e C

The observation sheet provides a platform for documenting and capturing observer insights regarding which system components work well together (facilitators), as well as challenges that occur between system components (barriers) during the simulations.

r o rf

g n ti s Te SHEET NO.#

LAYOUT LAYOUT

& n g i s com

SYSTEMS OBSERVATION SHEET

POST-ENACTMENT FOCUS GROUPS

START TIME -

Impeded view (posture change)

Please mark note-taker location on plan

The observation sheet provides a platform for systematically tracking each individual surgical team member’s movement during a simulation and recording observed flow disruptions (FDs).

EXAMPLES OF SAFETY RELA

ROLE - Circulating Nurse SIMULATION - Pediatric Laproscopic hernia repair

Cluttered pathway (posture change)

NOTE-TAKER -

Furniture / equipment conflicts

PATH OF TRAVEL OBSERVATION SHEET

Obstacle (route change)

WHAT’S IN THE TOOL?

SETUP

INDUCTION

PROCEDURE

INDUCTION ROOM

EMERGENCE

VIDEO AND PHOTO CAPTURE Capturing the simulations through both video and photo documentation provides a platform for further in-depth analysis of FDs once the simulations are completed.

BREAKDOWN

Systems observation | December 2018

OR FLOW MODELING

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

To date, there are no clear measures of how workflows interact within the operating room. It is difficult for designers and managers to predict how changes to one part of their system (e.g, one workflow) will affect the other parts of the system. Reliable performance of surgical procedures requires that all flows be coordinated to occur within constraints of the OR. A key project goal was to identify how physical constraints of the OR design affect workflows. One tool used to help accomplish this goal was discrete-event computer simulation and Markov chain modeling.

This tool is well suited for analysts with technical knowledge of computer simulation methodologies. However, its purpose is to support design decisions being made and questions being asked by any healthcare professional that is working with a process improvement project team.

H r o f r

e D s

WHY USE THE TOOL?

Designers and planners will often develop proposals that cannot be fully tested without some level of physical simulation. However, physical simulations require time, planning, and are not always possible. Through this project, we demonstrated the value of supplementing physical simulation with computer-based simulation to compare operating room designs that improve workflow metrics while maintaining or enhancing safe surgery. For example, using this method we were able to compare operating room designs that minimize key workflow metrics (travel time, travel distance, density/ congestion, surgical flow disruptions, etc.) while maintaining or enhancing safe surgery. This method was also used to support research focused on reducing microbial load in the OR.

e i t i l i c a F h

lt a e

& n g i s

e t n e C

PROBLEM ANALYSIS

DESIGN

DEVELOPMENT

IMPLEMENTATION

EVALUATION

WHAT’S IN THE TOOL?

ANIMATED COMPUTER SIMULATION MODEL

KEY PERFORMANCE MEASURES CAPTURED WITHIN THE OR COMPUTER SIMULATION MODEL a. Total distance walked during each surgery b. Frequency of staff members needing to adjust their route (or path) based on proximity to another staff member (i.e., contacts) c. Frequency of staff members impeding on the surgical area when that area was not their destination d. Occupancy within each zone in the room

MODEL 1: “SIMULATED PLAYBACK” COMPUTER SIMULATION MODEL

e D s

e i t i l i c a F h

Videotaped surgeries were coded for locations and activities by staff member The simulation creates agents to represent each staff member in the room Model 1 provides a simulated playback of the actual videotaped surgeries, with tracking of locations and activities and associated statistics Provides a visual representation of flow and movement of OR staff

& n g i s

g n ti s Te

Snapshot during intra-operative phase

lt a e

H r o f r

MODEL 2 : “MARKOV CHAIN” COMPUTER SIMULATION MODEL

e t n e C

Zones are classified as either pass-through or destination Data from videotaped surgeries provides a “likelihood” of moving between any two destination zones, as well as a dwell time in each zone. This is fed into the Markov chain simulation model Comparative design analysis can be performed that allows for destination zones to be placed anywhere within the room layout

Heat map displaying density of activity

CAPACITY ANALYSIS MODELING

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

Simulation modeling is an analytical tool that allows the testing of changes in a virtual environment to see how it will impact the system. Sometimes this analysis is done to determine the capacity of a new space or the operations of an existing space. In the Capacity Analysis Modeling Tool, we worked with a previously designed space to answer questions regarding capacity and operations. Our method included collection of a one-year retrospective data set from three different outpatient settings. We aggregated this data set to evaluate existing processes and predict future operational changes in this model. We also used focus groups and architectural data to build our database in order to test operating room schedules (block schedules) for this new ambulatory surgery space. The model can help plan the ideal utilization of induction room space and help plan the ideal block schedule.

This tool was created for strategic planning leadership, process improvement professionals, clinical staff, and facility planners. This tool can be used to inform users about how various changes can impact the system, whether those changes are related to capacity, service line, or scheduling changes. When future questions arise, the model can be a critical analytical tool to help guide decision makers.

H r o f r

e t n e C

PROBLEM ANALYSIS

DESIGN

e D s

WHY USE THE TOOL?

The tool should be used to study the impact of patient volume changes on the system and its affect on necessary room capacity. The capacity to consider includes the number of pre-op and post-op beds, the number of available OR rooms, and the number of induction rooms.

e i t i l i c a F h

lt a e

& n g i s

The tool can also be used to study the impact of block schedule changes on the system. Changes to the OR schedule can have an impact not only on the OR department but also downstream from the OR department. Testing proposed block schedules in the simulation model prior to implementation can help determine the right schedule for the system.

WHATâ&#x20AC;&#x2122;S IN THE TOOL? The model provides the user with easy access to the most useful model parameters. All model parameters are contained in the integrated model database. The model database makes using the model easy by organizing the data in such a way to make it straightforward to find and modify the data.

DEVELOPMENT

IMPLEMENTATION

EVALUATION

The Capacity Analysis Modeling Tool contains the following components:

NOTEBOOK WINDOW

NOTEBOOK WINDOW The model provides a control panel called the Notebook window. The Notebook window control panels are used to guide the model user on typical model inputs needed to control the model, as well as the typical model outputs used for reporting results. The Notebook windows contains controls to set parameters as well as buttons to open specific database tables. The notebook window has been organized to help the user navigate various tasks.

e D s

MODEL WORKSHEET

e i t i l i c a F h

The model worksheet visually shows patients flowing through the system. The model worksheet also shows high level results of the model run. From here, the user can access the input and output notebook windows.

MODEL DATABASE

The model database contains the following information tables that can be accessed through the notebook window. a.

& n g i s

g n ti s Te

MODEL DATABASE

lt a e

The model database contains the OR block schedule which allocates the OR resources to the various surgical services. This table makes it easy for the user to change when and which OR rooms the surgical services use by a simple dropdown menu selection. The service times for each process in the system are contained in their own table and are broken down by anesthesia type and surgical service. This data came from actual historical patient data but can be changed by the user as the new process changes improve the system. The architectural data has been included in the database which contains the distances staff and patients must travel from point A to point B. The total distance traveled is reported at the end of the model run. The floor plan is to scale of the final design. Patient arrival data has been included in the model database. This allows the user to control the number of patients per week using the OR as well as the surgical service probabilities.

H r o f r

e t n e C c.

SAFE OR DESIGN TOOL

g n ti s Te

OVERVIEW

WHO SHOULD USE THE TOOL?

The OR is a complex and dynamic system where highly skilled clinical teams interface with a myriad of technologies, equipment and critical care processes. As part of the OR work system, the built environment can be a crucial component in helping mitigate adverse outcomes, such as surgical site infections, task disruptions, and staff injury, that pose potential safety risks to both patients and clinical team members. Grounded in the work that has been conducted over the last four years of the RIPCHD.OR research project, the Safe OR Design Tool provides an opportunity for multiple stakeholders to understand the implications of design on safety in the OR. This tool supports an evidence-based approach to designing new or renovating existing ORs to provide a safer more ergonomic OR environment for patients and staff.

The Safe OR Design Tool was developed to engage multidisciplinary design teams comprised of clinicians, designers, and researchers in a more collaborative design process when designing OR environments, and to provide a comprehensive understanding of how different design elements impact safety in the OR using a systems approach. The tool can also support multiple stakeholders in understanding how the built environment can be leveraged to increase safety in the OR.

H r o f r

e t n e C

PROBLEM ANALYSIS

DESIGN

e D s

WHY USE THE TOOL?

e i t i l i c a F h

lt a e

& n g i s

Multidisciplinary design teams may find this tool helpful when implementing design strategies into the design or redesign of new or existing ORs to support targeted outcomes such as improving visual and information awareness, improving movement and flow, and reducing disruptions. Additionally, this tool could be used to conduct post-occupancy evaluations of existing ORs to determine design interventions that could be implemented to increase patient and staff safety within the OR environment.

WHATâ&#x20AC;&#x2122;S IN THE TOOL? The web-based tool provides an opportunity to interact with components in an OR environment through a 3D model. The web interface allows users to explore design strategies and their associated desired outcomes for a series of design elements commonly found in OR environments. Additionally, users of the tool may filter design strategies by the type of strategy it is within the work system and access citations associated with each design strategy.

DEVELOPMENT

IMPLEMENTATION

EVALUATION

TECHNOLOGY

STRUCTURAL SYSTEM

The Safe OR Design Tool contains the following components:

CIRCULATION ZONE

DESIGN ELEMENTS A series of 14 design elements provide a focused platform for accessing design strategies and desired outcomes for commonly found features within the OR environment.

BOOMS

DESIGN STRATEGIES These actionable statements provide guidance on how to implement a design strategy into the OR environment to support a desired outcome.

& n g i s

An associated description is provided for each design strategy addressing why that specific strategy is important to consider based on current literature or PSLL findings.

ANCILLARY SPACES

e D s

e i t i l i c a F h

RATIONALE

lt a e

DESIRED OUTCOMES

Desired outcomes that have been linked with evidence to the associated design strategy are provided to address how the design strategy can improve safety and quality in the OR.

H r o f r

TYPE OF EVIDENCE

WINDOWS DOORS

g n ti s Te

WORKSTATION

The type of evidence, broken into 4 distinct categories, and full citation for each combination of design strategy and desired outcome is provided for usersâ&#x20AC;&#x2122; reference.

e t n e C

ANESTHESIA ZONE

TYPE OF STRATEGY Each design strategy is tagged to provide insight into which OR work system component is impacted by the associated design strategy.

STORAGE

FURNITURE & EQUIPMENT SURGICAL TABLE

STERILE ZONE

INTERIOR SURFACES

LAYOUT

SAFE OR DESIGN TOOL DESIGN ELEMENT: Layout

DESIGN STRATEGIES Locate computer workstations in close proximity to surgical team membersâ&#x20AC;&#x2122; related tasks.

& n g i s

Provide expansion opportunities to accommodate future technologies and equipment.

e D s

Locate movable equipment in close proximity to surgical team membersâ&#x20AC;&#x2122; related tasks.

e i t i l i c a F h

DESIRED OUTCOMES

Size the OR to accommodate all surgical team members and their associated tasks and equipment.

Improve movement and flow Reduce risk of contamination (latent strategies: low touch surfaces, cleanable high touch surfaces, copper)

e H r o rf

alt

Reduce bacterial load (active strategies: UV light, airflow)

e t n e C

Improve ability to adapt over time Reduce disruptions

Provide clearly defined circulation, anesthesia, and sterile zones.

During planning phases, locate and clearly identify circulation, anesthesia and sterile zones according to surgical team members related tasks.

Improve efficiency

Improve workplace ergonomics

g n ti s Te

TYPE OF STRATEGY

Provide standardized room layout across ORs within the same facility and service line.

DESIGN ELEMENT: OR Table

DESIRED OUTCOMES

DESIGN STRATEGIES

Reduce slips, trips, and falls

Provide an OR table with integrated cord management.

Improve flexibility

Improve movement and flow

e D s

Improve information awareness

e i t i l i c a F h

Improve workplace ergonomics Reduce disruptions

DESIGN ELEMENT: Workstation

DESIRED OUTCOMES

lt a e

Position OR table so it can accommodate multiple orientations and locations to maximize room utilization.

DESIGN STRATEGIES

Improve workplace ergonomics

Provide height and monitor angle adjustable mobile workstations.

Improve visual awareness

Provide easily cleanable workstation surfaces.

H r o f r

e t n e C

& n g i s

Provide an OR table with adjustable components that can be easily assembled and disassembled.

Improve efficiency

Reduce risk of contamination (latent strategies: low touch surfaces, cleanable high touch surfaces, copper) Improve movement and flow

g n ti s Te

TYPE OF STRATEGY

Position circulating nurse workstation for visual access to both the OR table and traffic entering and exiting the OR. Provide computer workstations that allow surgical team members to face the sterile field irrespective of the OR table position.

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

Future State OR

& n g i s

g n ti s Te

Predicting the future in healthcare is challenging, particularly in surgery. It is clear that the rate and scope of change in surgery has been dramatic over the last half century and will only continue to accelerate. Advances in both medical and related technologies, anesthesia, medical science, reimbursement, regulation, and demographics along with the constant drive to reduce costs, improve outcomes and increase patient satisfaction have all contributed to a significant migration of surgical procedures from the inpatient to the ambulatory settings. Historically inpatient procedures like gall bladder surgery, knee and hip replacement, and reconstruction are now routinely performed as outpatient surgeries. Likewise, outpatient care including minor surgical procedures will migrate to even less sophisticated settings. While understanding what will change is unclear, the drive toward better, safer, faster and less expensive surgery is certain. The bottom line is that the ambulatory surgery operating room (OR) needs to be designed to accommodate an increasingly wide range of surgical procedures, technologies and practices, some of which we can predict and some that we may not even imagine today. Therefore the primary objective of the RIPCHD.OR was to design a flexible and adaptable chassis that could accommodate a range of current and potential surgical procedures and technologies rather than a singular design.

e D s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

THE MARCH TOWARD INCREASING AMBULATORY SURGERY

g n ti s Te

Various forms of ambulatory surgery have been recorded since antiquity, including procedures in the home and on the battlefield or on ships. Some of the earliest documented forms of what we might consider modern outpatient surgery were performed in the 1890s . Advances in pharmaceuticals, anesthesia and minimally invasive surgical arthroscopic and laparoscopic technologies have enabled the rapid increase in ambulatory surgery procedures over the past half-decade. Image guidance, both internal and external, and robotics are contributing to the expansion of ambulatory surgery today and into the future. Electronic Medical Records (EMRs) and Picture Archiving and Communication Systems (PACs) are also significant enablers, as well as the ability to access and visualize medical information. The surgical site and the procedure itself will also continue to influence the design of ambulatory surgery and procedure rooms. Virtual and augmented reality has the potential to enable surgical visualization and precision, the hallmark of recent outpatient surgery advances. Inventory control and supply chain management advances are enabling remote materials processing. As anesthesia continues to advance, the potential for the patient to be more awake and alert in the operating room will also change current dynamics in the ambulatory OR environment and drive the design of the OR toward less intimidating and stressful settings with increased control of the sensory environment and attention to the patient experience. Technologies employed in the OR will inevitably increase and new technologies will be introduced that will need to be accommodated. At the

Types of outpatient procedures performed in ASC’s

The Society for Ambulatory Anesthesia was formed in 1984 and has rapidly expanded

Outpatient Robot-Assisted Radical Prostatectomy (RARP) had been reported by 2010

(Burden, 2005)

(Banapour et al, 2019)

1990’s 2010

1988

1982

1980’s

(Burden, 2005)

1976

(Hedley-Whyte and Milamed, 2005)

The first freestanding ambulatory surgery center opened in Phoenix, Arizona with a focus on gastroenterology, pain management, gynecology and orthopedic cases

1975

1960’s

e t n e C

Number of ASC’s

The first disposable anesthesia system meeting ANSI and ISO standards was employed for outpatient surgery in 1968

lt a e

H r o f r

e D s

e i t i l i c a F h

1960s saw early forms of hospital-based outpatient surgery

1970’s

The first reported ambulatory surgeries were performed in the US employing general anesthesia in 1918

1910’s

1890’s

The earliest outpatient surgery was performed in Glasgow, Scotland

& n g i s

1,000

ASC’s

200

2000

types of procedures types of procedures

g n ti s Te

same time, as technologies mature they often become less intrusive and demanding on the physical environment and allow for the reduction of the increasing amount of institutional clutter common in most ORs today. However, as existing technologies mature new technologies continue to be introduced and have the potential to continue to add to equipment clutter in the OR. The challenge in the future will be to constantly find ways to reduce the increasing tendency toward institutional clutter in the OR and to make the space less intimidating, safer, easier to clean and maintain. Beyond advances in medicine and surgical procedures, new integrated lighting systems, wireless technologies, integrated digital display technologies, as well as materials and systems designed to improve infection control all have the potential to transform ambulatory surgery environment, and the RIPCHD.OR was conceived to anticipate these and other advances. It is important to note however that the RIPCHD.OR was not developed in detail, modeled, simulated or evaluated for the technologies shown, or the emerging and future state conditions identified in this chapter beyond the conceptual layout of various technologies and systems. The scenarios illustrated are simply attempts to examine how the flexible chassis might accommodate other emerging procedures and technologies. It is also important to note that the entire RIPCHD.OR study was limited to the boundaries of the Operating Room Space and to some extend those support spaces that require direct access to the OR.

ASC’s

3500

types of procedures

The most common procedures performed in ambulatory surgical settings (excluding cosmetic surgery) as of 2017 included various forms of eye surgery, esophageal procedures, colonoscopies (both diagnostic and lesion removal), spinal/nerve blocks and subcutaneous injections, ENT, knee and shoulder arthroscopy/ surgery

2017

(Bert, Hooper & Moen, 2017)

2015

e D s

e i t i l i c a F h

Elective outpatient total joint arthroplasty including knee and hip TJAs grew 47% between 2012 and 2015, and projected to grow 77% over the subsequent decade

lt a e

(Pallardy and Vaidya, 2014)

H r o f r

e t n e C 5,300

Almost half of mastectomies were performed as outpatient surgeries (Appleby, 2016). At least 8 ambulatory surgery centers also had Robotic Surgery Systems

2013

2011

23 million surgeries were performed across ASCs in the United States

5,400

6,100

ASC’s

& n g i s

REFERENCES

Banapour, P., et al. (2019). Safety and feasibility of outpatient robot-assisted radical prostatectomy. J Robot Surg. Apr;12920, 261-265. Bert, J., Hopper, J., & Moen, S. (2017). Outpatient Total Joint Arthoplasty. Curr Rev Musculoskelet Med, 10:567-574. Republished online in Springer Science+ Business Media, LLC 2017. Burden, N. (2005). Outpatient Surgery: A View Through History. Journal of PeriAnesthesia Nursing (Vol. 20), No 6 December, 435-437. Hedley-Whyte, J., & Milamed, DR. (2006). The evolution of sites of surgery, Ulster Medical Journal, 75 (1), 46-53. Pallardy, C., & Vaidya, A. (2014). 8 Ambulatory Surgery Centers With Robotic Surgery Systems. Retrieved August 8, 2019, from https://www. beckersasc.com/lists/8-ambulatory-surgery-centerswith-robotic-surgical-systems History - Ambulatory Surgery Center Association (ASCA). Retrieved August 8, 2019, from https://www. ascassociation.org/aboutus/whatisanasc/history# Appleby, J. (2016). More Women Are Having Mastectomies And Going Home The Same Day. Retrieved August 8, 2019, from NPR.org website: https://www.npr.org/sections/healthshots/2016/02/22/467644987/more-women-arehaving-mastectomies-and-going-home-that-day

PLUG AND PLAY COMPONENTS IN THE OR

g n ti s Te

The RIPCHD.OR is designed as a flexible chassis that is planned to accommodate interchangeable configurations of ancillary spaces. The immediate suite can be configured with an entry/scrub alcove, equipment storage room, induction room, instrument preparation or breakdown room, imaging control room and/or electrical equipment rooms. The RIPCHD.OR chassis has the potential to be configured to work in either a single corridor, work core, or clean core departmental concept. It assumes a 28-foot column spacing in the long direction of the room chassis, but would it require different column grid dimensions in the other axis depending on the suite layout.

The walls are designed as modular wall panels that can be removed for repair and reconfigured for various integrated utility systems, window systems and integral digital displays. The ultimate goal was to minimize institutional clutter and minimize horizontal surfaces and corners for easy maintenance and cleaning.

e t n e C

e i t i il

A.Z.

4'- 0"

S.Z.

4'- 0"

14' - 3"

4'- 0"

C.Z.

S.Z.

4'- 0" 4'- 0"

26' - 0"

c a F h

4'- 0"

e D s 22' - 0"

lt a e

H r o f r

24' - 0"

4'- 0"

14' - 3"

The ceiling and wall systems are designed and envisioned as a kit of parts and plug and play systems. The ceiling includes a modular structural ceiling frame for the flexible location and relocation of overhead booms, lights, and imaging equipment as needs change over time. While the mockup did not include a finished ceiling, a modular ceiling system including lighting and HVAC is envisioned.

& n g i s

FLEXIBLE ROOM CHASSIS

The 22 foot by 26 foot OR itself is planned with a two-foot-deep interstitial zone around the perimeter to accommodate recessed storage, recessed equipment, fixed and movable equipment alcoves, scrub sinks and/or staff work surfaces all of which can be reconfigured as needs change.

PRIMARY CHASSIS

SECONDARY CHASSIS

TERTIARY CHASSIS

A.Z. Anesthesia zone | C.Z. Circulation zone | S.Z. Scrub Zone

SINGLE CORRIDOR

C.Z.

CONTROL

Control Room

CONTROL

EQUIPMENT

Control Room

34' - 0" 24' - 0" 22' - 0"

10' - 0"

34' - 0"

34' - 0" 24' - 0"

10' - 0"

A.Z.

S.Z.

C.Z.

A.Z. S.Z.

C.Z.

S.Z.

C.Z.

A.Z.

SUPPORT SPACES

S.Z.

SURGICAL SUPPLY STORAGE

A.Z. S.Z.

S.Z.

C.Z.

6' - 0"

14' - 3"

24' - 0" 22' - 0"

14' - 3"

26' - 0"

14' - 3"

S.Z.

EQUIPMENT

CONTROL

CLEAN CORE

S.Z.

14' - 3"

SUPPORT SPACE

CONTROL

EQUIPMENT

A.Z.

S.Z. H

S.Z.

C.Z.

C.Z. 6' - 0"

S.Z.

34' - 0"

10' - 0"

& n g i s EQUIPMENT

e D s

e i t i il

CONTROL

26' - 0"

S.Z.

BREAKDOWN

CONTROL

6' - 0"

14' - 3"

A.Z.

26' - 0"

14' - 3"

A.Z.

14' - 3"

C.Z.

SUPPORT SPACE

14' - 3"

S.Z.

C.Z.

14' - 3"

S.Z.

SUPPORT SPACE

A.Z.

26' - 0"

14' - 3"

e t n e C H

14' - 3"

H r o f r

C.Z.

SUPPORT SPACE

S.Z.

lt a e S.Z.

S.Z.

26' - 0"

14' - 3"

S.Z.

26' - 0"

14' - 3"

SUPPORT SPACE

C.Z.

A.Z.

SUPPORT SPACE

S.Z.

c a F h 10' - 0"

SUPPORT SPACE

14' - 3"

26' - 0"

S.Z.

6' - 0"

14' - 3"

A.Z.

24' - 0"

SUPPORT SPACE

24' - 0"

34' - 0"

34' - 0" 24' - 0" 22' - 0"

26' - 0"

24' - 0" 22' - 0"

WORK CORE

ALCOVE

Breakdown Room

Induction Room

SUITE OPTIONS

ALCOVE

SINGLE CORRIDOR

BREAKDOWN

EQUIPMENT

6' - 0"

Prep

No Ancillary Rooms

ALCOVE

SINGLE CORRIDOR

INDUCTION

g n ti s Te 4

26' - 0"

PREP

ALCOVE

EQUIPMENT

ALCOVE

14' - 3"

INDUCTION

BREAKDOWN

26' - 0"

PREP

INDUCTION

26' - 0"

2 SINGLE CORRIDOR

ALCOVE

SINGLE CORRIDOR

PREP

SINGLE CORRIDOR

OPTIONS FOR ADJACENT SUPPORT SPACES 1

IMAGE GUIDED PROCEDURES

g n ti s Te

It is predicted that outpatient surgery will soon include an increasing number of image-guided procedures now commonly performed in hospital-based Hybrid ORs or interventional procedure rooms. Cardiac catheterization and angiography has been performed as an outpatient procedure for several decades. The RIPCHD.OR chassis has been conceived to accommodate the integration of cardiac catheterization and angiography equipment, including overhead CT and Fluoroscopy equipment, an associated control room, electronic equipment, and associated storage in several configurations. Control and equipment room[s] can either be located between two operating rooms or between the OR and corridor. Other forms of imaged guided procedures are emerging that involve both virtual reality and augmented reality. It remains unclear how these technologies may impact the design of the operating room.

Option A

EQUIPMENT ROOM 152 SF

CORRIDOR

12'-0"

SCRUB

CONTROL ROOM 270 SF

APRONS

4'-0"

17'-0" 4'-0"

1'-0"

2'-0"

1'-0" 1'-0"

4'-0"

10'-0"

4'-0"

2'-0" 4'-0"

SUPPLY

EQUIPMENT ROOM 132 SF

CORRIDOR

CONTROL ROOM 150 SF

10'-0" SCRUB

O.R.

4'-0"

613 SF

4'-0"

700 SF

4'-0"

He O.R.

28'-0"

alt

SUPPLY CATHETER

4'-0"

15'-0"

4'-0" 4'-0"

il tie

22'-0"

2'-0"

1'-0" 1'-0" 1'-0"

4'-0"

4'-0" 4'-0"

26'-0"

28'-0"

4'-0" 4'-0" 4'-0"

r o rf CRASH CART

e t n e C 2'-0"

1'-0" 1'-0"

20'-10"

1'-0" 1'-0" 1'-0"

4'-0"

3 26'-0"

APRONS

SUPPLY

4'-0"

26'-0"

9'-0"

i c a F h

4'-0"

2'-0"

4'-0"

1'-0" 1'-0" 1'-0"

4'-0"

1'-0" 1'-0" 1'-0" 1'-0"

4'-0"

26'-0"

2'-0" 4'-0"

15'-5 1/2" CRASH CART

2'-0"

1'-0" 1'-0" 1'-0"

4'-0"

22'-0" 4'-0"

24'-0"

1'-0" 1'-0" 1'-0"

2'-0"

24'-0"

8'-2"

24'-0"

10'-0"

1'-0" 1'-0" 1'-0"

e D s

SCENARIO 2

Option B

CATHETER / SUPPLY

SUPPORT ROOMS

SCENARIO 1

& n g i s

g n ti s Te

It is important to note that there can be significant variation in how cardiac catheterization and angiography rooms are configured depending on the procedures performed, clinician preference, and vendor equipment requirements. The scenarios illustrated simply represent examples of some potential configurations possible within the chassis framework. The configurations tested for the RIPCHD.OR chassis assume the anesthesia work area would typically be located at the head of the patient, with the interventionalist and sterile instrument table positioned at patients right side. Other configurations could be accommodated through the reorganization of access and support spaces. The scenarios 2-4 allow for the electronics equipment closet to accommodate access directly from the corridor or the control room. While all scenarios work with a 28-foot structural bay in the long direction of the OR chassis, scenarios 2-4 examine how the suite and support room sizes could be accommodated with a 28x26, 28x28 and 28x30 foot structural bay.

r o rf

662 SF

2'-0"

CRASH CART

CATHETER / SUPPLY STORAGE

e t n e C LEGEND

9'-0"

O.R.

range and movement of C-arm range and movement of overhead bridge

Anesthesia workstation

Cath/Angio eqipment with overhead bridge

Mobile Circulating Nursesâ&#x20AC;&#x2122; workstation

range and movement

4'-0"

7'-0"

4'-0"

CORRIDOR

4'-0"

12'-0"

9'-0" 2'-0"

4'-0"

9'-0" 4'-0"

4'-0"

EQUIPMENT ROOM 120 SF

CONTROL ROOM 141 SF

CORRIDOR SCRUB

O.R. 686 SF

C-arm

Cath/Angio eqipment with overhead bridge

4'-0"

SUPPLY

4'-0"

2'-0"

1'-0" 1'-0" 1'-0"

4'-0"

CRASH CART CATHETER

CATHETER

SUPPLY

movement of patient bed

C-arm

range and movement of C-arm

SCRUB

22'-0"

4'-0"

APRONS

10'-2"

110 SF

4'-0"

9'-0"

alt

CONTROL ROOM

e i t i il 2'-0"

1'-0" 1'-0"

4'-0"

8'-0 1/2"

4'-0" 4'-0"

26'-0"

28'-0"

c a F h

109 SF

Cath/Angio eqipment with overhead bridge

4'-0"

EQUIPMENT ROOM

APRONS

4'-0" 1'-0" 1'-0" 1'-0"

4'-0"

SUPPLY

C-arm

9'-0"

10'-0"

4'-0"

1'-0" 1'-0" 1'-0"

3 30'-0"

26'-0"

4'-0"

2'-0"

1'-0"

28'-0"

4'-0"

9'-0"

5'-0" 4'-0"

30'-0"

4'-0"

2'-0"

1'-0" 1'-0" 1'-0"

4'-0"

22'-0" 4'-0"

28'-0"

8'-0 1/2"

3 28'-0"

10'-2"

2 28'-0"

1'-0" 1'-0" 1'-0"

2'-0"

e D s

SCENARIO 4 Option D

SCENARIO Option C3

1'-0" 1'-0" 1'-0"

& n g i s

Instrument prep table

range and movement of C-arm range and movement of overhead bridge movement of patient bed

ROBOTIC SURGERY

g n ti s Te

Given robotic surgery is already being performed in ambulatory surgery centers, the OR chassis is designed to anticipate the space needed for robotic equipment. Robotic surgery has been performed to date generally in conventional ORs but requires additional space for the surgeonâ&#x20AC;&#x2122;s control equipment and special considerations around the OR table for the robotic equipment. Depending on the type of surgery, the robot and surgeons console, as well as the anesthesia zone and sterile instrument tables are positioned in different locations in the OR. Current robotic surgery systems are designed for use in conventionally designed operating rooms, and involve a cumbersome control console and some models involve mobile display equipment in the room that includes cabled connections between the various pieces of equipment. Yet, the original concept behind robotic surgery suggested the surgeon could conceivably be located anywhere outside the OR. It is possible to envision that the surgeons console will someday disappear, with the surgeon migrating to an adjacent control room (scenario 4) or literally being virtually rather than physically present altogether. Display equipment could also migrate to walls and booms rather than located on a cart as is presently required.

4'-0"

2'-0"

1'-0" 1'-0" 1'-0"

4'-0"

613 SF

Option 01: Robot Equipment on patient side

2'-0"

22'-0" 4'-0"

4'-0"

SUPPLY

4'-0"

28'-0"

4'-0"

O.R.

1'-0" 1'-0" 1'-0"

2'-0" 1'-0" 1'-0" 1'-0"

4'-0"

26'-0"

4'-0"

1'-0" 1'-0" 1'-0"

2'-0"

1'-0" 1'-0" 1'-0"

lt a e

H r o f r

4'-0"

1'-0" 1'-0" 1'-0" 1'-0"

24'-0"

26'-0"

4'-0"

28'-0"

4'-0"

e t n e C 4'-0"

4'-0" SUPPLY

4'-0"

2'-0"

22'-0" 4'-0"

4'-0"

2'-0" 1'-0" 1'-0" 1'-0"

24'-0"

SCENARIO 2

e D s

e i t i l i c a F h

SCENARIO 1

& n g i s

O.R. 613 SF

1'-0" 1'-0" 1'-0" 1'-0"

4'-0"

Anesthesia workstation

range and movement of C-arm range and movement of overhead bridge

Circulating Nurses’ workstation

movement of patient bed

LEGEND MEDICAL PERSONNEL

Instrument prep table

g n ti s Te

ROBOTIC SURGERY EQUIPMENT

EQUIPMENT

Surgeon

Anesthesia workstation

Circulating Nurse

Surgeon Console

& n g i s

Scrub Tech

Mobile Circulating Nurses’ workstation

Anesthesiologist

Instrument prep table

e D Option A s e i t i l i c a F h

Robotic Equipment

Patient

Layout and robotic surgery equipment details adapted from Anesthesia Da Vinci Surgery | Da Vinci Surgical System | Robotic Technology. (n.d.). Retrieved August 8, 2019, from daVinci Surgery website: https://www.davincisurgery.com/da-vinci-systems/about-da-vinciworkstation

SCENARIO 4

2'-0"

1'-0" 1'-0"

4'-0"

10'-0" 4'-0"

4'-0"

8'-2"

EQUIPMENT ROOM

CORRIDOR

Robotic Equipment

CONTROL ROOM 10'-0"

O.R. 9'-0"

700 SF

15'-5 1/2" CRASH CART

2'-0"

4'-0"

SCRUB

613 SF

10'-0"

4'-0"

28'-0"

O.R.

2'-0" 4'-0"

SUPPLY

2'-0"

1'-0" 1'-0" 1'-0"

1'-0"

4'-0"

17'-0" 4'-0"

Surgeon Console

26'-0"

4'-0"

1'-0" 1'-0" 1'-0"

22'-0"

4'-0"

26'-0"

1'-0" 1'-0" 1'-0"

28'-0"

4'-0"

1'-0" 1'-0" 1'-0" 1'-0"

3 26'-0"

4'-0"

lt a e

H r o f r 2

e t n e C 4'-0"

4'-0"

Instrument prep table 2'-0"

1'-0" 1'-0" 1'-0"

2'-0"

1'-0" 1'-0" 1'-0"

4'-0"

SUPPLY

4'-0"

2'-0"

22'-0"

1'-0" 1'-0" 1'-0"

26'-0"

24'-0" 2'-0"

Circulating Nurses’ workstation 1

SUPPORT ROOMS

SCENARIO 3

INFORMATION DISPLAY IN THE OR The RIPCHD.OR is envisioned to allow for various forms of information display on overhead booms and in numerous locations embedded in the wall system. The goal is to provide ubiquitous access to various forms of relevant medical information and surgical imagery to each member of the surgical team irrespective of their location and orientation in the room. Wall displays would ultimately be integrated into glass wall panels and smart glazing systems, eliminating traditional wall mounted monitors. 3D Virtual Reality and Augmented Reality projection over the patient and surgical site may also ultimately need to be accommodated.

H r o f r

e D s

e i t i l i c a F h

lt a e

& n g i s

g n ti s Te

display zone

movable equipment zone

ELEVATION A

e t n e C

display zone

movable equipment zone

ELEVATION B

LIGHTING The Operating Room must accommodate a variety of lighting needs and conditions from general lighting for set up, uniform bright light for cleaning, targeted lighting for surgical procedures, and dim-able or colored background lighting for image guided procedures. The RIPCHD.OR is envisioned to allow for different lighting needs over the surgical procedure cycle from pre-operative phase, perioperative phases, post-operative phases and room turnover. The need for ambient lighting becomes increasingly important as the use of general anesthesia diminishes and patient has the potential to be more alert at any given point in the surgery. There is increasing interest in introducing daylight and windows in the OR for both patient and staff benefit, yet this requires consideration for functional needs, thermal and light control systems. These diverse and highly variable needs require special attention and emerging forms of OR lighting are evolving. Surgical lighting booms have the potential to impact the clean airstream over the patient and conflict with each other and other ceiling mounted equipment. New concepts, such as the Optimus Integrated Surgical Environment and its associated Celestial Surgical Lighting System, employ an array of robotic LED lighting fixtures that are imbedded in the ceiling plane and controlled remotely based on the need, location, and type of lighting required.

e D s

& n g i s

e i t i l i c a F h

g n ti s Te

Patient Arrival

Patient Prep

Surgical Phase

Post Operative

lt a e

H r o f r

e t n e C

Operating Room Design and Integration - Optimus Integrated Surgical Environment (ISEâ&#x201E;˘), the Operating Room of the Future. (n.d.). Retrieved August 8, 2019, from Optimus Integrated Surgical Environment website: https://www.optimus-ise.com/

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

Next steps

& n g i s

g n ti s Te

It has been an incredible opportunity to see the genesis of the RIPCHD.OR learning lab over the last four years. As we have moved through an iterative cycle from problem analysis, design, testing, design refinement and implementation, to now evaluation, there have been many lessons learned along the way. As we see the culmination of our efforts, we recognize that those lessons learned will continue to impact not only the final stages of this research project, but also future research studies.

e D s

e i t i l i c a F h

lt a e

H r o f r

e t n e C

NEW ASC FACILITY POST-OCCUPANCY EVALUATION With the new pediatric surgery center now open at MUSC Childrenâ&#x20AC;&#x2122;s Health R. Keith Summey Medical Pavilion, efforts are underway to conduct a post-occupancy evaluation (POE) to understand how the system components are working together in the new environment. The focus of these evaluations will be on understanding the impact of the physical environment on staff workflow and safety outcomes. Video observations similar to those in year 1 will be conducted, and the results from the post-occupancy evaluations will be compared with data collected in years 1 and 2. MUSC has also planned to build an orthopedic ASC in the Charleston metro area. The potential exists to conduct POEs in that facility as well in the future.

& n g i s

g n ti s Te

e D s

e i t i l i c a F h

lt a e

H r o f r

e t n e C

Design: LS3P | Photography: Stanley Capps

CONTINUED LEARNING

g n ti s Te

The high-fidelity mock-up will remain at the Clemson Design Center in Charleston through the remainder of 2019 and Spring of 2020, and will continue to serve as a learning lab for students in the Architecture + Health Program at Clemson. It will also be available for other interested groups to use as a learning and demonstration resource. The learning lab will be used to provide practical application of human-centered design principles and support studentsâ&#x20AC;&#x2122; understanding of critical design considerations in the OR, and demonstrate how to integrate research into complex and dynamic healthcare design projects.

EXTENDING CURRENT RESEARCH

& n g i s

e i t i l i c a F h

e D s

Work from this research project has been extended into another AHRQ grant funded research study focused on reducing errors in perioperative anesthesia medication delivery. This new research project is a collaboration between Medical University of South Carolina, Clemson University, and Johns Hopkins University, and will continue through 2020. The goal of this project is to use human factors engineering to design interventions to reduce anesthesia medication errors in operating rooms.

lt a e

H r o f r

APPLICATION TO OTHER ENVIRONMENTS

Over the course of the last four years, the RIPCHD.OR learning lab has provided great insight into how to leverage various simulation methods to support a human-centered approach to the design of healthcare spaces. The research and prototype design framework and methods that were developed, employed, and refined on this project are envisioned to be applicable to other healthcare spaces where critical patient care and treatment is delivered and in settings that are replicated over and over again in the design of healthcare facilities.

e t n e C

e D s

& n g i s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

g n ti s Te

Dissemination

& n g i s

g n ti s Te

The project findings have been successfully disseminated to a wider audience through efficient channels like journal publications, conference proceedings and presentations delivered across the country and internationally as well as poster sessions, webinars, and workshops. The design charrette (September 2016) and the OR high fidelity mockup unveiling reception and workshop (January 2018) were conducted at the CDC.C during critical times in the project to share findings and gain feedback from clinicians, researchers, architects, and the Advisory Committee. These events were also used as opportunities to print and distribute “Realizing Improved Patient Care Through Human Centered Design in the Operating Room | Volume 1 and Volume 2”. Short videos of the mock-up construction and evaluations have been shared via social media and at conferences. The team has been lauded for their accomplishments through the Gold level Evidence-Based Design “Touchstone Award” and “Healthcare Environment Awards” in the conceptual design category in November 2017 at the Healthcare Design Expo+Conference. Our work has also garnered much attention in local and national media and has been profiled in several news reports such as the MUSC Catalyst News, The Wall Street Journal and Outpatient Surgery Magazine.

e D s

lt a e

e i t i l i c a F h

e t n e C

H r o f r

WORKSHOPS CLIENT

Leo A Daly, Miami, FL

WORKSHOP LOCATION

Miami, FL

& n g i s

OBJECTIVE The purpose of this workshop was to provide a collaborative work session with Leo A Daly and Mount Saini Medical Center to support further design development of the renovation of the medical centerâ&#x20AC;&#x2122;s new C-section rooms.

e i t i l i c a F h

Provide an engaging platform for clinical end users to participate in the design process Understand the current flow of all users, as well as materials and supplies within the new OR Anticipate future changes in workflow and technology that may impact the design of the new C-section rooms Build consensus between the design team and clinical team regarding the optimal layout of the proposed new C-section rooms

lt a e

e t n e C

H r o f r

ACTIVITIES

Flow diagram development Journey model exercise Scenario-based gaming ideation session Debriefing exercise

e D s

Tour of the existing facility

Flow diagram development

Scenario-based Gaming Ideation Session

g n ti s Te

CLIENT

Emory University , Atlanta, GA

WORKSHOP LOCATION

Charleston, SC

& n g i s

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

OBJECTIVE

g n ti s Te

A SYSTEMS APPROACH TO EVALUATING ORTHOPEDIC PROCEDURES DURING HIGH-FIDELITY SCENARIO-BASED SIMULATION TESTING IN A PHYSICAL MOCK-UP Emory Workshop | February 25, 2019

The purpose of the engagement between the Center for Health Facilities Design and Testing at Clemson University and Emory University was to understand impact of workflow or technology on OR layout in the newly built operating rooms at the Musculoskeletal Institute.

e i t i l i c a F h

Provide in-depth information related to planning and design of a safer and more human centered OR for orthopedic surgery Conduct a collaborative workshop to develop an OR layout that meets the specific needs of the project under consideration

lt a e

ACTIVITIES

H r o f r

e D s

Web presentation

ANJALI JOSEPH | Ph.D., EDAC DEBORAH WINGLER | Ph.D., EDAC

Tour of the OR mock-up

Phase 1 Web presentation to the design and clinical teams to share how to utilize a human-centered approach to understand workflow and behavior patterns in the OR.

e t n e C

Phase 2 Flow diagram development Journey model exercise Scenario-based gaming ideation session Scenario-based simulations in the high-fidelity mock-up Debriefing exercise

Scenario-based Gaming Ideation Session

MEDIA COVERAGE THE WALL STREET JOURNAL May, 2018 5/29/2018

I N F O nC & U S

The Operating Room of the Future - WSJ

DOW JONES, A NEWS CORP COMPANY

DJIA Futures 24561 -0.68% ▼

S&P 500 F 2700.50 -0.65% ▼

Stoxx 600 384.84 -1.28% ▼

U.S. 10 Yr 13 32 Yield 2.881% ▲

g n ti s Te

THE HEALTHCARE DESIGN MAGAZINE December, 2018

Crude Oil 67.27 -0.90% ▼

ig s e

S T R A T E G I C A P P R O A C H E S to D E S I G N C H A L L E N G E S

This copy is for your personal, non-commercial use only. To order presentation-ready copies for distribution to your colleagues, clients or customers visit http://www.djreprints.com.

D s

https://www.wsj.com/articles/the-operating-room-of-the-future-1527559862

JOURNAL REPORTS: HEALTH CARE

The Operating Room of the Future

e i t i l i c a F h

A host of changes hold out the promise that surgery will be more ef icient, more e ective and less risky for patients

lt a e

Dr. Scott Reeves and Dr. Anjali Joseph are leading a joint research team from Clemson University and the Medical University of South Carolina to design safer, more ef icient operating rooms. PHOTO: MIC SMITH PHOTOGRAPHY LLC

By Laura Landro May 28, 2018 10�11 p.m. ET

The operating room is getting smarter, more eﬀective—and a lot less risky for patients.

H r o f r

Hospitals are investing in new devices, designs and digital technologies that promise a new era of innovation for surgery. The moves are part of a growing shift away from traditional open procedures that involve big incisions, lots of blood loss and long hospitalizations. They point toward a future where more patients can choose minimally invasive outpatient surgeries, with faster recoveries, fewer complications, and less pain and scarring.

JOURNAL REPORT

e t n e C Insights from The Experts