whd_2012_patient unit comparison study

Retaining the Caring Presence and

Healing Touch in New Generation

Asian Hospitals: Learning from the

American Experiment

8TH DESIGN & HEALTH 2012 KUALA LUMPUR

Agenda

Introduction – Decentralization

Study Objectives

Context – MD Anderson Cancer Center

Data Collection

Findings

Summary

INTRODUCTION

Drivers and Design Impacts

Single patient rooms

Larger footprints

Proximity challenges

Decentralization

Decentralization

Use of technology

Healing presence/time at the bedside

Teamwork

Hypothesized Impacts

Patient focused

More time with patient

Improved efficiencies

Reduced non-productive time

Reduced walking distance

Collaboration, teamwork and mentoring?

Stress reduction?

Chaos, noise

Socialization

Productivity improvement

OBJECTIVE

Objective

To examine the impact of decentralization on operational

efficiency and teamwork – drivers of the healing touch

and caring presence.

Goals of the Study for MD Anderson

Assist in adaptation to the new unit design

Identify new processes for

Communication

Collaboration

Task completion

Larger unit footprint

Seek opportunities

Education and training

Modify design elements

STUDY CONTEXT

Texas Medical Center (42 member institutions, 13 major hospitals with 66,000 employees)

A healthcare component of the University of Texas

Founded in 1941, M. D. Anderson has grown to over 18,000 faculty and staff

More than $2.2 billion annual revenue

M.D. Anderson Cancer Center

M.D. Anderson Cancer Center Growth

1998 – 1999

20% growth in patients

1999 – 2008

80% growth in patients

75% increase in

employees

115% increase in

research revenue

2012 Projections

50% growth in patients

from 2006

Then and Now

Typical Nursing

Floor

(4) 13-bed Units

All Private Rooms

Central Nurse

Station

Racetrack Design

Service & Public

Elev.

Albert B. and Margaret M. Alkek Hospital

THEN

Central Nursing

Station

Albert B. and Margaret M. Alkek Hospital

THEN

Unit Configuration

Centralized work

concept

Open medication

prep areas

Family waiting areas

small/lacking

Wayfinding

challenges

THEN

Key Design Goals and Objectives

The new Alkek patient units were designed reviewing

current evidence-based concepts in a manner that:

Promotes patient and family centered care

Maximizes efficiency of work effort for all members

of the care team

Includes ergonomic considerations that minimize the

physical burden of patient care delivery

Promotes interdisciplinary collaboration

NOW

1. Improved staff

circulation within

core

2. Decentralized

staff stations at

patient rooms

3. Decentralized

meds and

equipment

4. Created team

rooms

1 1

22

3

3

3

3 4

44

4

Design Solutions - Staff

NNOW

Decentralized Nurse/Staff Stations

• Decentralized nurse/staff stations

with patient view window

• Improved view of patients for

assessment purposes

• Encourages staff time with

patients

• Decreases staff travel time

• Distributed supplies/linen

• Creates quieter environment

Storage rooms and alcoves

• Maintain hallways free of

equipment

• Support service areas (Lab,

Nutrition)

TEAM

MEDS

SUPPL

Y

Unit Staff Support Areas

NOW

Inpatient Floors 15–17

Typical patient room Increased room size (ranges from 251 s.f.–298 s.f.)

Outboard toilet improves visibility of patient

ADA-sized toilet enhances accessibility

Improved family space

Easier access to patient

Caregiver work area within patient room

PPE alcove outside room

NOW

DATA

Data Collection

J F M A M J J A S O

BEFORE DATA AFTER DATA

UNIT A

UNIT B

UNIT C

UNIT A

UNIT A NEW

UNIT B NEW

UNIT C NEW

2011

Data Collection Protocol

14 staff data points for day shift/14 data points for

night shift (per unit)

RNs carried PDAs and completed corresponding

pedometer logs

PDA vibrates 30 times/12 hours, tasks and location

entered

Filled out surveys

Data Types

Nursing time:

Rapid Modeling PDA

Walking distance:

Pedometer

Acute stress:

Current Mood State Questionnaire

Presenteeism:

Koopman Stanford Presenteeism Scale

(Modified)

Staff interaction and collaboration

KU Scale

TCAB PDA

PDA TCAB Data Classification

Task Type

Value adding

Non value adding

Necessary

Task Category

Direct care

Indirect care

Administrative

Personal

Waste

Documentation

Other

Task Location

Nurse station

Patient room

On the unit

Patient medication

Supply storage

Conference room

Off unit

Documentation server

Other

FINDINGS

Identifying Patterns of Change

Care processes, physical environment, culture and policies interact

PATIENT

PATIENT OUTCOMES

PHYSICAL ENVIRONMENT

CAREGIVER CARE PROCESSES

GROUP PHENOMENA: CULTURE RELATIONSHIPS

POLICIES

Identifying Patterns of Change

Multiple unit

comparison benefit

Identifying Patterns of Change

Performances change after intervention

The key question is consistency

PDA Task Category: Documentation

15

17

19

21

23

25

27

29

31

33

Unit A Unit B Unit C

Before

After

PDA Task Location: Nurse Station

25

27

29

31

33

35

37

39

41

43

45

Unit A Unit B Unit C

Before

After

PDA Task Location: On The Unit

0

2

4

6

8

10

12

14

16

Unit A Unit B Unit C

Before

After

PDA Task Location: Medication

0

2

4

6

8

10

12

14

Unit A Unit B Unit C

Before

After

PDA Task Location: Supply Storage

0

0.5

1

1.5

2

2.5

Unit A Unit B Unit C

Before

After

Pedometer Walking Distance

1.5

2

2.5

3

3.5

4

Unit A Unit B Unit C

Before

After

Collaboration/ Teamwork

Question Direction Significance?

UNIT PRIMARY WORKSPACE

The amount of space in your primary

workspace fits your needs

UP 1 OF 3

You have sufficient work surfaces in your

primary workspace for your equipment and

work

UP 1 OF 3

You have enough storage space in your

primary workspace

UP 2 OF 3

You can change your workspace as needed

to fit your needs

UP 1 OF 3

PRIVACY IN PRIMARY WORKSPACE

You have enough privacy in your primary

workspace to do your job (e.g.,documentation,

charting, and/or dictation) well.

UP 0 OF 3

Collaboration/ Teamwork

Question Direction Significance?

PRIVACY IN OTHER SPACES

You feel that you are not interrupted by

others as you work in patient rooms

DOWN 0 OF 3

You feel that you are not interrupted by

others as you work in medication room/s

DOWN 0 OF 3

ENVIRONMENTAL FEATURES

Your primary workspace gets enough natural

light

DOWN 0 OF 3

Your primary workspace has sufficient

illumination for your needs

DOWN 0 OF 3

You are able to control the temperature in

your primary workspace when needed

DOWN 0 OF 3

You are able to control air

velocity/movement when needed

DOWN 1 OF 3

Collaboration/ Teamwork

Question Direction Significance?

UNIT WORK SUPPORT

When you need a computer, there is one

available

UP ALL

You can easily monitor your patients from

unit workspaces

DOWN 0 OF 3

The people you need to work with are

available in the unit when you need them

DOWN 2 OF 3

Overall, you are pleased with the design of

your unit in relation to your work

DOWN 0 OF 3

Collaboration/ Teamwork

Question Direction Significant?

COLLABORATION + TEAMWORK

Overall, the layout of your unit supports

teamwork or collaboration

DOWN ALL

Your unit has adequate space for formal

team meetings

UP ALL

Your unit has adequate space for informal

team meetings or interactions

UP 1 OF 3

Meeting spaces are generally available in

your unit

UP 1 OF 3

Patient rooms are large enough for

teamwork and collaboration

UP ALL

Corridors are wide enough for informal

interactions

UP 1 OF 3

Collaboration/ Teamwork

Question Direction Significance?

WALKING

You spend more time walking in your unit in

relation to other activities

UP 2 OF 3

Walking takes away from the time you would

otherwise have for patient care

UP ALL

Walking takes away from the time you would

otherwise have for collaborative work

UP 2 OF 3

Focus Group Interviews

The Nurses Speak…

Increase in computerized documentation

Medication room is now farther from many rooms. Lots

of walking

Location of pneumatic tube station

Finding “other staff” difficult

Different processes for medication record use on each

unit

Lessons Learned

Operational planning vs reality

Paper intensive processes

Added Telemetry reduced ICU census

Geographic patient assignments new reality

Chemo and blood products require two-nurse checks

Feelings of isolation

Missed ‘teachable moments’ for new staff

Infection control discussions

Medications “at the bedside” on the wish list

Cannot get all supplies to the bedside

SUMMARY

Operational design must match physical design

intervention to achieve desired outcome

Culture change is the most important challenge

Unit size and shape appears to be key determining

factors affecting collaboration and teamwork

Healthcare

Pamela Redden, MD Anderson

Cancer Center

predden@mdanderson.org

Debajyoti Pati, Texas Tech

University

d.pati@ttu.edu