CONTENTS. 05
Personal Learning Objectives
07
Forms & Required Training
09
Clinical Facility Visits Greenville Memorial Hospital | Facilities Development Medical Center Powdersville Greer Memorial Hospital | Emergency Department Greenville Memorial Hospital Med Surge | 3D Greer Memorial Perioperative Services Greenville Memorial Hospital Perioperative Services
32
Personal Reflection
33
Summary
34
Appreciation
PERSONAL LEARNING OBJECTIVES. During this shadowing experience I aim to absorb as much knowledge as I can from those who live in the clinical environments which architects design. Those who “live” in these environments include patients, their families, nurses, doctors, and other staff members. The ultimate goal is to have a broad knowledge of various departments’ and the process by which patients and staff move throughout the space. I will obtain this knowledge by way of observation, conversation, and interaction with those who have experience in the following settings: Facilities Management
* * *
What is it like to experience the design and construction process as the owner? Do clinical staff have a significant role in this process? What are some lessons learned in facilities management that are valuable to outside architects?
Outpatient Clinic
* * *
What is the process of payment for the institution and the patient? What are the motivating factors to increase outpatient efforts? What are the patient and staff challenges?
Emergency Care
* * *
What is the flow process of the patient, family, staff, and physician? What are some of the important items architects must consider but often forget when an emergency unit is designed? What are the basic challenges of delivering emergency care?
Inpatient Care | Med Surge
* * *
What is the nurses’ role in the inpatient environment? How can the patient arrive in this department? What are a few of the struggles nurses deal with on a daily basis?
Perioperative and Surgical Services
* * *
How do perioperative staff interact with the surgery team? How are family members accounted for? What is critical in surgical suites?
5
FORMS & REQUIRED TRAINING. HLTH 6200 CLEMSON UNIVERSITY ARCHITECTURE + HEALTH OBSERVATION FIELD OBSERVATION FORM Student name:
Rachel M. Matthews
Telephone: Student E-mail: Facility Contact: Dale Corr Facility Contact phone number: Facility Contact E-mail: Internship site address:
701 Grove Road ________________________________________________________________ City: Greenville State: South Carolina Zip:
29605
Please type and attach‚ pages as needed to this form to provide the following information: 1. Field project description: Describe in as much detail as possible the nature of the facility[s] and settings you will be observing and the scope of your observations. List settings, staff you will observe, meetings planned or other activities, etc. 2. Supervision: Describe in as much detail as possible any supervision to be provided at the facility being observed, how often you plan to meet with the contact, etc. 3. Evaluation: Describe how your engagement with people and observations at the site should be evaluated. Your daily log of times and activities will be part of your project notebook, so you should keep track of timelines, meeting times, etc. 4. Learning goals and objectives: What do you intend to learn through this field experience? This is the lengthiest part of form 2—since you are to describe what you hope to learn and how you think you will learn it at the identified internship site. Signatures: Student: ________________________________________
7
FORMS & REQUIRED TRAINING. Selection | Greenville Health System
Greenville Memorial Hospital is located just west of downtown Greenville, South Carolina. It is home to upstate’s Greenville Health System which boasts services in primary care, orthopaedics, neurosurgery, behavioral health, radiology, cancer care, rehabilitation, general and specific surgery, pediatric care, vascular care, women’s health, and general medicine. Because of the vast amount of services GHS offers the shadowing experience offered in different departments, even at different facilities provided a wealth of knowledge. Tuberculosis Skin Test GHS Online Training
This is to Certify Rachel Matthews has completed the course "New Volunteer Orientation" 5/25/2016
CLINICAL FACILITY VISITS. Greenville Memorial Hospital Facilities Development Dale Corr, Mark Loukides, and Rick Spitz, AIA June 10, 2016 | 7 hours
Medical Center Powdersville MD 360 Urgent Care | Surgery & ENT Charlotte James, RN | Nursing Supervisor June 17, 2016 | 7.5 hours
Greer Memorial Hospital Emergency Department Laura Morris, RN | Nursing Supervisor June 24, 2016 | 8 hours
Greenville Memorial Hospital 3D Med Surge Inpatient Unit Abby Colwell, RN & Michelle Julian, RN, BSN July 7, 2016 | 9 hours
Greer Memorial Hospital Perioperative & GI Services JoAnna Travaglini, RN, BSN | Perioperative Supervisor July 22, 2016 | 7 hours
Greenville Memorial Hospital Perioperative Services & Surgery Department Genia Harvey, RN, BSN July 29, 2016 | 7.5 hours
9
GREENVILLE MEMORIAL HOSPITAL FACILITIES MANAGEMENT
The priority of this particular day was to receive an overview in the facilities development department at Greenville Hospital System (GHS). First, Rick Spitz, the director of architecture, educated me in regards to close-out documents. We visited about the responsibilities the department has as the voice of the owner, GHS. By having inhouse facility services the owner is more apt to have successful new building projects. The facilities department has five-year contracts with three main architects in Greenville: McMillian Pazdan Smith, LS3P, and Design Strategies. These different firms receive different types of work based on their expertise, experience, and scope of work. This particular visit also consisted of an overall tour of the main hospital, Greenville Memorial Hospital (GMH). The largest project currently is the renovation of the new intensive-care unit which is due for completion in the next few months. Its sister unit was recently completed. A
A-B | The main entrance into GMH includes the typical reception desk as well as the automatically playing piano, but over the years several buildings were closed in to make a pleasant atrium. Several inpatient rooms have indirect daylight access via windows out to this atrium. Mark Loukides began my initial tour of the main hospital by the Welcome Plaza facility map. He included commentary regarding the overly complex set of icons which intend to simply illustrate various locations in the building. Over the next few years GHS intends to implement simplified signage designed by a well-known design company in order to decrease wayfinding issues currently present. C | The first logo of the Greenville General Hospital before it became GMH.
10
B
C
D
D | Building a mockup of a possible ICU patient room aided GMH and staff in making decisions regarding equipment locations, access to daulight through a shared lightwell, and equipment necessary in order to serve the patient. E-F | At GMH the usage of automated guided vehicles (AGV) are the sole source of managing the environmental and food services in the hospital. Extensive time and care was taken in preparing the facility as well as the robots themselves in order to successfully perform its tasks. The AGVs have their own dedicated elevators in order to decrease disruptions in human performed services.
E
G
H
F
DALE CORR G-H | GMH is currently constructing phase II of their intensive care unit. Dale is responsible for coordinating construction to minimize the amount of clinical interruptions. His position did not exist until a few years ago. Previously he held the position Director of Nursing for GMH and was responsible for approximately 300 nursing supervisors. The facilities development department has found that he is vital to successful construction projects. They have experienced a decrease in complaints caused by construction interruptions, therefore a decrease in clinical disruptions and a positive patient experience.
Inter-clinical relationships and knowing who to call is key in coordinating construction projects and keeping patient care ongoing, 24-7, 365 days a year 11
MEDICAL CENTER POWDERSVILLE MD 360 | SURGERY & ENT
Medical Center Powdersville includes a variety of services including physical therapy, orthopaedic medicine, imaging, sleep lab, an MD 360 (urgent care), two CTs, as well as an ENT (Ear, nose, and throat) department. The MD 360 and ENT clinics are the two most utilized portions of the medical center. The physical therapy clinic utilizes a separate check in area but shares the same central waiting area (3A) as the other clinics. In many areas the building appeared to be used in ways contrary to the intended design. All staff members that were engaged in conversation claimed to be not yet employed by GHS when the programming and design took place for the facility. This proves to be a huge missed opportunity and results in a misallocation of space. Interesting elements in the medical center include the central check in point as well as that being the location of given payment. Often prices of expected services are given to the patient before payment is accepted, which gives the patient opportunity to not check in and leave the facility. Functional Diagram TO CT & SLEEP LAB PROCEDURE IMAGING
ORTHOPEDIC
MD 360 EXAM ROOMS NURSE STATION
12
E&T NS.
EXAM ROOMS
EXAM
CHECK OUT* CHECK IN & PAYMENT
PHYSICAL THERAPY
EXAM ROOMS
ADMIN
RR
LAB C/S BREAK
WAITING COMMUNITY
ENTRANCE
OS E R IT V AU IN H C
O IN P 8 5 3 0 -2 K TR V A L YIR
SAFETYBEAM
EXTERIOR
EMER GEN CY BR EAK O U T
SAFETYBEAM
EXTERIOR
SAFETYBEAM
EXTERIOR
SAFETY BEAM
EMER GEN CY BR EAK O U T
EMER GEN CY BR EAK O U T
OS E R IT V AU IN H C
EMERGEN CY BREA K O U T
EXTERI O R
User Process and Flow
2
5A
DOCS 151
5
4-6 5-6 3-4
2
3
NURSE STATION 152
5
3 5-6 4-5 3-4
6*
4
1
4
1 3
3A 2
2
7 1
Patients 1. Arrival & Parking 2. Entrance 3. Check In & Payment a. Non-emergent Wait 4. Triaged by nurse 5. Examined by doctor 6. Discharge 6*. Designed Discharge station 7. Departure
Clinical Staff
Doctors
1. Arrival & Parking 2. Lockers & Break Room 3. Report to Nurses Station and monitor Epic 4. Verbally call back next patient 5. Triage patient 6. Administer medication as instructed by MD
1. Arrival & Parking 2. Report to station and monitor Epic or fulfill other duties (MDs rotate through several facilities) 3. Assess patient 4. Instruct nurse to provide medication 5. Chart via audible handheld remote or manually typed 13
EXTERIOR
EMER GEN CY BR EAK O U T
EXTERIOR
SAFETYBEAM
MD 360 | SURGERY & ENT | CONTINUED Positive Aspects ++ Access to daylight ++ Natural finishes ++ Beautiful central waiting area
DOCS 151
E
G
NURSE STATION 152
Negative Aspects
F
–– One central waiting area, meaning very sick patients wait with well patients –– Columns disrupting high traffic areas for staff –– Minimal security –– No dark exam rooms for eye issues
D C
F
A
B
A
A | The main entrance into the Powdersville Medical Center offers modern, upscale finishes. Some patients have noted that it almost feels too fancy to receive care there. B | Clear and precise signage aides visitors in locating the proper entrance as well as where to park. C | The central waiting lobby boasts of beautiful finishes as well as an abundance of natural light. Unfortunately the central check in requires that sick sit next to healthy patients.
14
SAFETYBEAM
SAFETYBEAM
EXTERIOR
SAFETY BEAM
-
EMER GEN CY BR EAK O U T
EMERGEN CY BREA K O U T
EXTERI O R
+
EMER GEN CY BR EAK O U T
OS E R IT V AU IN H C
INY P 8 5 3 0 -2 K O T V A L RR I
OS E R IT V AU IN H C
INY P 8 5 3 0 -2 K O T V A L RR I
MEDICAL CENTER POWDERSVILLE
B
C
D
D | The three above images demonstrate the finish selection and overwhelming size of the lobby in which patients and their families wait. The left image is the barrier between the public waiting area and the MD 360 nurses’ station. E | The MD 360 nurses’ station had the least amount of criticism. It possess the capability of seating 4-5 people as well as small work stations behind. At times this area can be very loud but overall is successful. F | Staff have options of eating in the break room or outside away from the distractions work can bring during the required lunch break. G | Example of an exam room in MD 360. It is important to consider what nurses and doctors need to reach within the first moments of triage and examining the patient.
E
F
Considerations MD 360 • X-Ray and Lab should be close • Amenities within the department would be nice, not just central break room • Doctors should have private space yet easily accessible by nursing staff • Standardize where the necessary instruments are in each room for easy access during urgent cases • Intuitive and personable wayfinding • Restroom needed near pelvic exam rooms • Overlap workstations to accommodate for shift layovers
G
ENT • Doctors need their own conveniently located space. Currently there is a designated space for them, yet it is out of the way and therefore never used. • Nurses’ station should be accessible by doctors and patients when necessary, yet should remain private in order for patient confidentiality to remain intact.
15
GREER MEMORIAL HOSPITAL EMERGENCY DEPARTMENT
The Greer Memorial Hospital is located just northeast of Greenville at the Greer Medical Campus. Services offered include emergency care, women’s health, and diagnostic services. The emergency department is one of the busiest most over utilized portions of a hospital. At Greer Memorial is it like most emergency departments where Mondays are the busiest. Currently emergency departments suffer from over utilization due to patients not having primary care providers or proper access to a primary care physician. These individuals appear in the ER with minor cuts, stomach aches, UTIs, etc. EDs are also the location for trauma cases such as car accidents. Staff incur some of the most interesting and dangerous individuals. Security in and around an ED is extremely important and often a metal detector would be on the top of the nursing supervisor’s wish list. Greer’s ED has approximately 90 cases per day while they are currently slated for only 60. Due to the recent change in computer software they are easily able to track their utilization and capacity which enables them to justify equipment purchases, staffing growth, and future facility growth. Functional Diagram
EMT
T. BAYS
DECON. TRIAGE
TREATMENT BAYS
T. BAYS
ADMIN
CHECK IN
NURSES’ STATION & WORK CORE
TREATMENT BAYS
EQ. STORAGE
TRAUMA ENTRY
BREAK ROOM & LOCKERS
TREATMENT BAYS
TO IMAGING
NURSE MANAGER
TREATMENT BAYS RESTROOMS
SECURITY WAITING
16
TO WOMEN’S CENTER
ENTRANCE
User Process and Flow
3 5B 5C ov s
1A 5 2
TK
o v s
PDC
PWT
IR BWS
ME HE
5A 3
MR
WS
MS ISO Isocenter
MWD
WT
UPS
PBC
COM
SM SD
REM
UPS
IR
CRC
OC VW
SM
PBK
OC
!
IC
UPS
T
3-4
PBC
TV
3A
4-6 4-8
3
5D WT
Isocenter
O
MU
WS
A MR
BWS
o v s
6A
S
V
A
O
INJ
V
A
MWD ISO
S
V
A
O
3B 3B
3A 2
CL
2 1B
1
1
Patients
Clinical Staff
1. Arrival A. Patient Drop Off B. Ambulance Drop Off 2. Parking 3. Check In A. Non-emergent Wait B. Triaged by nurse when busy 4. Escorted to treatment bay by volunteer or nurse 5. Medical history, vitals, etc. 6. Care plan administered A. Any necessary imaging 7. Monitored and discharged
1. Arrival & Parking 2. Lockers & Break Room 3. Report to Nurses Station and monitor Epic A. (OR) Retrieve patient B. Triage outside of treatment bay when busy 3. Medical history, vitals, minor triage, etc. 4. Receive orders from doctor 5. Administer care plan A. Print prescriptions, doctor signs, sent to pharmacy B. Retrieve available meds C. Retrieve supplies D. Any necessary imaging 6. Monitor and discharge patient
Doctor 1. Arrival & Parking 2. Report to station and monitor Epic or fulfill other duties (MDs rotate through several facilities) 3. Assess patient 4. Instruct nurse to provide care plan 5. Chart via audible handheld remote or manually typed and monitor Epic for upcoming patients
17
GREER MEMORIAL HOSPITAL EMERGENCY DEPARTMENT | CONTINUED
+
++ Convenient for the community ++ Volunteer escorts ++ Teamwork environment
O
ov s
A
ov s
A
Negative Aspects ov s
F
A
ov s
A
–– Minimal security measures –– Weak visibility from nursing stations into treatment bays –– Minimal patient restrooms available –– Lack of storage, therefore items are in inconvenient and hazardous locations –– Lack of staffing capabilities –– No access to daylight –– High patient to staff ratio, approximately 9:1
V
o v s
A
O
V
A
O
-
V
NO
Positive Aspects A
s
REVISIONS
C
TK
o v s
PDC
PWT
IR
TV
BWS
ME
HE
E
MR
WS
MS
MU
A
ISO
Isocenter
ovs
o v s
MWD
WT
UPS
o v
PBC
COM
SM
SD
MG
ME
REM
VW
SM
PBK
UPS
CRC
OC OC
!
IC
B
UPS
PBC
PBC
ME
Table Tilt Axis
IR
TV
WT
Isocenter
MU
INJ
BVS
O
MS
D
KEYPLAN
S
V
A
O
WS
MR
MS
BWS
o v s
CL
o v s
V
A
o v s
MU
MWD
ISO
S
V
A
O
A
CL
TRUE NORTH
GREER CAMPU MASTER PLANS GREER, SC DATE: SCALE: 1/16" = 1'-0"
HOSPITAL First Level Floor Plan
Treatment Bay Challenges
• • • • •
18
Stolen equipment: TV remotes, TVs, sodas... Chords, chords, chords Need locked nurse work stations Need Universal Room Orient mounted and place equipment to coordinate with what is actually done in the treatment bay (highlighted above)
Protocol
1. Patient gowns 2. Nurse takes vitals - blood pressure, O2 saturation, heart rate, and temperature 3. Patient lays down 4. Nurse charts 5. Doctor visits the patient
A & B | The entire waiting room has great access to daylight and the landscaping surrounding the building. C | Doctor on duty charts and checks Epic status between cases. D | The Greer ER often utilizes tele-medicine where a doctor on campus can communicate via technology with a patient. E | The nurses’ station in the ER is a social place where the care team communicates with one another and works together to accomplish the shift’s tasks. F | Explanation of how idiotic the treatment bays are at Greer made for a fun and lively conversation.
B
A
C
D
E
F
“Nurses and their supervisors should’ve designed this hospital.” 19
GREENVILLE MEMORIAL HOSPITAL 3D MED SURGE INPATIENT UNIT
Within Greenville Memorial Hospital there is a vast number of operating rooms, 33 to be exact. Very few of the surgeries performed are outpatient procedures with the rest being impatient and trauma. After the surgery is performed the patient is placed in an inpatient unit, also known as med surge. A patient can also be placed here after being stabilized but not healed in the emergency room. During the patient’s stay they are monitored by an RN every hour. A medical doctor, surgeon, etc. may also check in once a day or every few days to adjust the care plan as necessary. The nurse on staff has a 12 hour shift and is assigned to certain patient rooms which are in close proximity to one another. He/she is responsible for administering medications, checking vitals, and monitoring bodily outputs. The nurse then must chart at a workstation or workstation-on-wheels exactly what occurred with the patient and when. Technicians aid the nurses in patient care by providing help with bathing, feeding, using the restroom, and making sure they are overall comfortable. The most significant struggle in GMH’s 3D unit was the distance between the nurse’s particular patient rooms and the locked medication cabinet as well as the equipment closet. Some patients are more involved than others which requires more time than is required on average. The less time a nurse has to hike to retrieve medications or equipment the more time can be spent with the patient. Functional Diagram
PATIENT ROOMS
OPEN EQ. HOLDING
S.U. PATIENT ROOMS MEDS
PATIENT ROOMS
EQ STOR.
PATIENT ROOMS
PATIENT ROOMS
MD’S
NURSES’ STATION
PATIENT ROOMS 20
ENTRANCE
User Process and Flow 2-6 4
7
2-3
3
5 6B
8
6 2
9
4 6A
1
Patients 1. Arrival via elevator from surgical procedure 2. Arrive in patient room 3. Greeted by RN 4. Given medication Checked on every hour by assigned nurse. This could occur over several days depending on the patient’s condition and doctor’s assessment 5. Assessed by doctor 6. Discharged
1
1
Clinical Staff
Doctor
1. Arrival via public elevators 2. Check in at staff area/ breakroom 3. Receive update from previous nurse assigned to the same patient rooms 4. Check on each patient empty drains, urinary drains, etc. Done once an hour. 5. Chart updates and tasks completed at WOW outside of patient room 6. Retrieve any medications for upcoming administrations of meds A. Retrieve necessary equipment to monitor patient B. Retrieve necessary linens 7. Administer care plan 8. Continue charting 9. Report to daily update meeting
1. Arrival from other department 2. Report to patient room and assess patient 3. Discuss care plan with RN 4. Dictate and fill out paperwork
21
GREENVILLE MEMORIAL HOSPITAL +
-
3D MED SURGE INPATIENT UNIT CONTINUED Positive Aspects
++ Access to daylight in patient rooms ++ Spacious patient rooms with family suite available by one room
F
Negative Aspects –– Large amount of steps taken depending on assigned room locations to pyxis machine for meds –– High patient to staff ratio, approximately 5:1 –– Dietary items like soda given in patient rooms –– Crowded halls –– Emotionally and physically draining patients
C
A
A
A | Each patient has a hard copy of their chart which is located in a binder organizer at the main nurses’ station. B | Once a day the staff gather together to give report on the patients located within their department. The proposed care plan is discussed as well as anything else pressing about the patients’ condition. C | The main hall going back to the rooms Abby Colwell, RN was working. Most halls are full of WOWs as well as movable equipment necessary to administer care.
22
E
D
B
C
B
D | The back hallway where Abby did most of her charting was also full of staggered WOWs as well as warm food carts, movable equipment, etc. Abby appeared to be one of the only RN’s on duty that moved her WOW to each room. If she ever had to leave her station she would roll it back to the position as shown in picture D. E | The patient rooms are laid out for decentralized nursing stations, but due to the WOWs they are now wasted space except for the occasional land line telephone call when a personal vocera does not work. When any plastic coverings are needed a storage container provides access below the workstation.
D
E
The Patient Room F
F | The patient rooms are full of daylight while the staff workspaces are dark and dim. (Top Left) The family is provided two “comfortable chairs to rest in if staying with their loved one. At various times patients even spend time in these chairs. (Top RIght) The patient could be in an exterior viewing room, as shown, or an atrium viewing room. (Bottom Left) The patient has access to a storage cabinet, television, update board, and opening shelving. (Bottom Right) Another view of the footwall.
Considerations Staff • • •
Patients
Know the stations of high traffic for • staff and strategically disperse them • throughout the department Daylight access in corridors for moving staff Time is essential with high patient to staff ratios
Less clutter at the footwall Even more comfortable seating and sleeping conditions for long term stays
23
GREER MEMORIAL HOSPITAL PERIOPERATIVE & GI SERVICES
Greer Memorial Hospital offers both inpatient and outpatient surgical services. Overall the patient process is very clear and organized. Perioperative services at GrMH is very minimal but offers a variety of services for patients. Not only are general surgeries performed but also gastro introscopic, orthopedic, and etc. The general surgery area consists of pre-op bays that also double as post-op bays. In the GI area the patient begins and ends in the same room. The GI procedures are not fairly complicated therefore not incredibly long and the family can remain in the same room while their loved one is away. Turnover and timing is key in the GI department while the general surgery area is more flexible. GrMH surgery also has their own sterile processing department along with an area inside of the clean core for staging of upcoming case carts. Most of the nurses mentioned struggling with the placement of semi-permanent equipment such as inner-room/bay workstations which are attached to the wall, glove boxes, hand washing stations, gases, blood pressure cuffs, otoscope, family seating, etc. Within the GI procedure rooms the placement of electrical outlets and therefore required equipment placement proves to be a problem with various surgeons who perform differently. A storage deficit was mentioned in both departments. Equipment was being stored in unused negative pressure rooms, currently empty patient bays, in front of medication rooms, and blocking circulation pathways. Functional Diagram TO INPATIENT TOWER
STERILE PROCESSING
PROCEDURE ROOMS
GENERAL SURGERY PRE & ORs
24
ORs
WAITING
ENTRANCE
STAFF LOCKERS & BREAK
User Process and Flow 9 1 2
3
3
2A
4
1-4
3A
5 3
6-8 2
3,7
4-6 9 4-6 9-10
7 4-6 7-8
2
2
5
3 4-6 4-6 3 4-6 7-8 6-8
Patients 1. Arrival & Drop Off 2. Check-In A. Same day preassessment if necessary 3. Check-In at reception A. Waiting 4. Led to pre-op room 5. Gown 6. Give medical history, consent, prepped for surgery 7. Induction and surgery 8. Emergence 9. Post-op 10. Discharge
7
7
1
2
1
2A
1
8
9-10
Clinical Staff 1. Arrival & Parking 2. Drop off belongings in break room 3. Report to nurses’ station 4. Retrieve consent, vitals, medical history, etc. from patient 5. Administer any medications 6. Assist in preparing patient for surgery 7. Check on other patients (or) assist in surgery, GI only) 8. Post operative care for patient and discharge
Surgeon / Anesthesia
1. Arrival & Parking 2. Drop off belongings in break room A. Dress out 3. Check on patient 4. Induce patient 5. Surgery 6. Emergence 7. Check on patient in post op
Sterile Instruments 1. Hand washing of instruments 2. Pass through sterilizer 3. Temporary storage 4. Pack and cart preparation 5. Store packaged carts ready for the day’s surgery 6. Unpacked 7. Surgery 8. Counted and packed 9. Returned to central sterile
25
GREER MEMORIAL HOSPITAL +
-
PERIOPERATIVE & GI SERVICES CONTINUED Positive Aspects
++ Clear wayfinding and flow ++ Access to daylighting in public areas ++ Positive family waiting experience
C
H
E
Negative Aspects –– No access to daylight in patient areas –– Small staff spaces –– “Stuff” mounted everywhere, especially in patient areas –– Barely any storage whatsoever, especially in GI –– No plan for emerging technologies, bad place for workstation in every room
A
A | Natural daylight floods the waiting area. B | The reception area designated for surgery is also pleasant with access to a smiling volunteer as well as daylight.. C | Most nurses in the GI section of perioperative services work from WOWs which take up a considerable amount of hallway space.
26
B
G
D
B
C
F
A
D | The perioperative bays in general surgery have zero access to daylight and are disrupted with the unorganized items on the headwall. E-F | The GI patient bays are also unorganized in regards to “stuff” on the walls. Several nurses complained of the recently added work station and how their back is always to the patient and family. G | The GI procedure rooms are much smaller than the average operating room. These rooms were equipped with imaging technology as well as many unnecessary storage compartments. H | Scopes are cleaned and sterilized after use in the soiled equipment room next to the procedure room then stored.
E
D
F
G
Considerations Staff • • • •
H
Patients
Always consider the needs of the staff • Take into account the activities that • occur in the perioperative bays Staff amenities i.e., break rooms, • comfortable nurses’ stations, pause spaces, etc. Joint lounge spaces may cause contention or camaraderie
Access to daylight is poor Crowded patient spaces for family to join in the situation Positive public spaces add to the experience in a good way
27
GREENVILLE MEMORIAL HOSPITAL PERIOPERATIVE SERVICES & SURGERY DEPARTMENT
During this visit minimal time was spent with the perioperative services department and more so with the nursing supervisors of the surgery department. Towards the beginning of the visit several nursing supervisors in charge of cardiology, GI, and orthopedic were conducting an interview for a scrub technician position. The interview questions and discussion stressed relationships, respect for authority, knowledge, and confidence. In the operating room the leader is obviously the surgeon. The surgeon and scrub tech relationship is key as well as the tech to their supervisor. Everyone in the OR should be attempting to anticipate each move the surgeon must make to perform the surgery successfully, especially the scrub technician who possesses much less than half the education of the surgeon. If the relationships and personalities are compatible in the OR the less likely issues will occur during a surgery. The ultimate goal is to aide the patient and be a positive impact on their health. If someone poses an issue unrelated to the patient’s well being they are least desired to be in the OR. Most of the visit was spent in the OR control room which houses live feed to all the ORs, two call nurses, and one charge nurse. Overall, the OR is a well oiled machine and the team of surgeons, residents, anesthesiologists, CRNAs, circulating nurses, and scrub technicians must work together efficiently and effectively to provide adequate care for their patients.
+
Positive Aspects
++ Conveniently located control room ++ High traffic corridor has access to daylight
A | The newly renovated waiting room for loved ones and family members has beautiful, natural inspired finishes but with a complete lack of daylighting, other than a minor view into the public atrium. B | Back behind the red line, the OR circulation paths contain a number of alcoves convenient for storing equipment outside of the associated OR.
28
A
-
Negative Aspects –– Convoluted wayfinding and floor plan –– Minimal access to daylight throughout the department –– Malfunctions with the new software cause items to be missing from packs upon arrival in the OR and it takes time before being transported to the OR.
B
Functional Diagram PRIVATE 3
STAFF BREAK
BAY 20
BAY 19
BAY 18
BAY 17
BAY 16
PRIVATE 2
BAY 15
BAY 11
PATIENT TOILET
BAY 14
BAY 12
OR ENTRY
BAY 13
SUPPLIES
SOILED UTILITY
NURSE STATION
STAFF SUPPORT CORRIDOR
PRIVATE 1
CLEAN UTILITY
MED RM
BAY 10
BAY 8
BAY 9
PATIENT CORRIDOR
BAY 1
BAY 2
BAY 4
BAY 3
BAY 5
BAY 6
BAY 7 TOILET
OFFICE
IT CLOSET
STORAGE
TOILET
2106
OR ENTRY
216
233
MED GAS VALVES
MED GAS VALVES 3-WLS
3-WLS PPS
LASER
PPS LASER
SURFACE MOUNTED
SURFACE MOUNTED
PHO11 PHO11
ADS PPS
ADS PPS
PHO11 PHO11
PHO11
PHO11 LIT21
LIT21
T 3-WLS
T
3-WLS
TO INPATIENT TOWER
PHO11
LASER
3-WLS
PPS
ADS PPS
MED GAS ALARM PANEL 3-WLS
3-WLS
3-WLS
3-WLS T
3-WLS
T
T
T LIT21
LIT21
PHO11
PHO11
3-WLS
T
LIT21
LIT21
LIT21 PHO11
PHO11
PHO11
LASER
PHO11
PHO11
PHO11
PHO11
PHO11
T
LIT21 PHO11
PPS
PPS
ADS
ADS
PPS
PPS
ADS
PPS ADS
ADS
3-WLS
PHO11
PHO11
PHO11 PHO11
PHO11
PPS
PHO11
ADS
PHO11
RECESSED MOUNTED
LASER
LASER
PPS 3-WLS
MED GAS VALVES
RECESSED MOUNTED
PPS 3-WLS
MED GAS VALVES
LASER
RECESSED MOUNTED
PPS
LASER
RECESSED MOUNTED
PPS
3-WLS MED GAS VALVES
3-WLS MED GAS VALVES
LASER
PPS 3-WLS
MED GAS VALVES
MED GAS VALVES
EDGE OF EXPANSION JOINT STL31 STL21
WBA11
LCDM ABOVE
HAP11 HAP12 BUK11 HAP13
C ARM & MON
ISO11
EQB11
STATUS CAM ABOVE
HLTE HLTE
ANS21 NEP 11
HAP14
CUT21
24" A-CAB
STL11
TBL 11
SSK21
VSP11
TAB21
TAB41
2 CELL OMNI SSK21
CAT11
PTZ CAM ABOVE
DOC 11
DOC 11
ANS11
LFP21
LFP31
LFP11
LFP21
LFP11
LFP31
CAT11 PTZ CAM ABOVE
EQB11
TAB21
TAB41 STL21
LCDM ABOVE
WBA11
MSC21
HAP13 EQB11 CUT21
O/BED TBL
HLTE HLTE PTZ CAM ABOVE
DOC 11
ANS11
LFP21
CAT11
ANS21
PTZ CAM ABOVE
DOC 11
STATUS CAM ABOVE
C ARM & MON
EQB11
ANS11 STL11
24" A-CAB
SSK21
ISO11
TBL 11
TBL 21
2 CELL OMNI
CUT21
BUK11
NEP 11
LFP11
LFP31
EQB11
HAP14 HAP13
LFP21
LFP31
LFP11
C.G.
NEP 11 CAT11
HAP14
STATUS CAM ABOVE
ANS21
TAB 21
HAP12
BUK11
CAB31
C ARM & MON
STL11
SSK21
SSK21
HAP11
2 CELL OMNI
CAB31 MSC11
24" A-CAB
VSP11
ABOVE
TAB21
TAB41
STL31
ISO11
LCDM
WBA11
STL21
HAP14
VSP11
STL11 ISO11
TBL 21
STL31 HAP13
ANS11
24" A-CAB
C ARM & MON
2 CELL OMNI
CUT21
HAP12
NEP 11
ANS21 STATUS CAM ABOVE
EQB11
HAP11
HAP11 HAP12 TAB21
LCDM ABOVE
VSP11
TAB41
WBA11
STL21
MCS11
C ARM & MON
ISO11 STL11
STATUS CAM ABOVE
24" A-CAB
TAB 21
STL31
ANS21
STL21
NEP 11
TAB41
LFP11
VSP11
LCDM
WBA11
STL31
ANS11
ABOVE
TAB21 HAP11
CAT11
2 CELL OMNI
LFP21 CAB31
LFP31 PTZ CAM ABOVE
BUK11
HAP12 HAP13
EQB11
DOC 11
CUT21
HAP14
C.R.
EQB11
HLTE HLTE
EQB11
TAB21
LFP21
LFP31
BUK11
HAP12
TAB41
CAT11
PTZ CAM ABOVE
DOC 11 CUT21
HAP11
NEP 11
LFP11
STL21
TBL 21
HAP13 HAP14 LCDM ABOVE
VSP11
2 CELL OMNI
WBA11
STL31
ANS21 STATUS CAM ABOVE
CAB11
ANS11 20" A-CAB
MCS11
SSK21
STL11
SSK21
ISO11
ISO11 24" A-CAB
STL11
CAB31
STATUS CAM ABOVE
2 CELL OMNI
DOC 11
ANS21 SSK21
PTZ CAM ABOVE
ANS11
SSK21
LFP11
TAB 21
CUT21 LFP21
LFP31
ISO11
NEP 11 EQB11
CAT11
PTZ CAM ABOVE
STATUS CAM ABOVE
TAB21 LFP31
24" A-CAB
DOC 11
LFP11 EQB11
VSP11
BUK11
TAB41 ANS11
LCDM
LFP21
CAB11 LCDM ABOVE
VSP11 HAP14 HAP13
GB SHRP
ABOVE CAB11
EQB11
C.R.
2 CELL OMNI
CUT21
TAB21 HAP11 HAP12 HAP13 HAP14
WBA11
ANS21
BUK11
TAB41
HLTE HLTE WBA11
STL21
HAP12
STL11
STL31
STL21
SSK21
STL31
NEP 11
HAP11 CAT11
SSK21
C.G.
OR ENTRY FROM LOCKERS BELOW
C
OR Rooms
Pre-Op
Post-Op / PACU
Clean Core
Sterile Core
Support
D
Red Line
C | Within the OR control room there are two screens which can access live feed into the 33 different operating rooms. No recording is done of the procedures but the feed is used to aid with timing of upcoming procedures within the room. D | A scrub station is outside of each OR for every active member within the OR to use before and after a surgery.
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PERSONAL REFLECTION. The process of shadowing, or observing, in a variety of different healthcare departments and venues opened my eyes to several issues missing in these built environments in which care is provided to those who need it most. Other than convoluted wayfinding, the patient is priority one. No matter the acuity of the patient most any clinician will do whatever it takes to provide them anything necessary to not feel horrible. Cost is another priority. If space can be preserved or if costs can be cut by only having one pyxis machine for medication that is what will happen. The constant question begs to differ than managing an existing facility costs far more than the initial investment. These types of decisions cause staff to become burnt out for they will serve the patient to the utmost of their ability including running to retrieve medications, equipment, patients in other locations, etc. Nurses do the grunt of the work and their goals and tasks feel and appear as if unconsidered. Therefore they feel unconsidered and unvalued as employees. In other cases the typical situation appeared where the built environment is not currently used as intended i.e., decentralized workstations replaced by WOWs, empty workstations intended for discharge and checkout, wait room used for minor triage, etc. As architects our buildings and designs should be able to adapt and perform to the needs of its users. Designs to enforce particular behaviors have held some success but if everyone is not on the same page space and intent is wasted. Staff, especially nurses, feel as if they are glorified servers as if in restaurants. The patient is of utmost importance and any nurse will do anything it takes to serve them care instead of extra fries.
STAFF VOICES FORGOTTEN LACK OF STORAGE GLORIFIED WAITERS & WAITRESSES MAKE-SHIFT SOLUTIONS UNDERVALUED STAFF
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SUMMARY. After the first few sessions of shadowing I had an epiphany, what we discuss in our graduate studies at Clemson, especially in the healthcare program, is incredibly precise and current. The many issues that presently trouble our healthcare providers today are being discussed in lectures, classrooms, mentor discussions, studios, and interviews. How can I, as an aspiring architect and designer, make a difference? Who is the target for better design? How can we as an industry be better? What is better? Lots of questions which pose no absolutely correct answer. Of this particular answer this I am confident, I must listen. Not only I must listen to those who are wise in experience and knowledge of architecture but more importantly the clinicians who will be impacted by the particular built environment. I must understand the daily tasks of medical staff members as well as be willing to research and prove what is the best answer. Our designs must be rooted and grounded in solid evidence in order to successfully aid and impact those who live and work in these spaces. Understanding patients and their families as well as not forgetting the important voices of staff members is key in empowering them to provide the best care possible to our communities.
ACADEMIA VS. PRACTICE WE MUST LISTEN IMPACT OTHERS VIA THE BUILT ENVIRONMENT EVIDENCE FOR DESIGN UNDERSTANDING OUR AUDIENCE EMPOWERING THE BEST CARE POSSIBLE
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APPRECIATION. As demonstrated, shadowing in clinical environments with an architectural background has provided a wealth of priceless knowledge. In order to properly thank those who took time out of their day to answer questions, give tours, etc. thank you cards were mailed on August 1st and 3rd.
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