E74: Teaming Up

Does unit decentralization impact teamwork and

operational efficiencies?

Pamela Redden, MS, BSN,RN, EDAC, Director, Clinical Facilities Development

UT MD Anderson Cancer Center

Janet Sisolak, Project Director

UT MD Anderson Cancer Center

Debajyoti Pati, PHD, FIIA, LEED AP.

Executive Director, CADRE; Rockwell Endowment Professor, Texas Tech

Acknowledgments

HKS Architects

- Study sponsor and institutional support

Center for Advanced Design Research &

Evaluation (CADRE)

Texas Tech University

- Institutional support

Learning Objectives

Understand the impact of decentralization on

the way nurses spend their time (efficiency).

Understand the impact of decentralization on

walking distance.

Understand the potential influence of

decentralized operations on presenteeism and

acute stress of care providers.

Understand the impact of decentralization on

care providers’ teamwork and collaboration.

Agenda

Drivers of decentralization

Key questions

The evidentiary challenge

The MD Anderson project

Study data

Key findings

INTRODUCTION

Bed utilization:

• Male – Female

• Smoker – Non

Smoker

• Infection

Build fewer beds

Increase

flexibility

Driver of Decentralization: Single Room

Key Area of Change # 1

Increase in floor

area per patient:

• Larger footprint

for the same

number of beds

Key Area of Change # 2

Support space

optimization:

• Race track

configuration

• Decentralization

Hypothesized Impact Areas

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

Agenda

Drivers of decentralization

Key questions

The evidentiary challenge

The MD Anderson project

Study data

Key findings

Key Questions

Does decentralization influence time spent

in walking, queues, and hunting and

gathering?

Does it reduce non-productive tasks?

Key Questions

Does decentralization influence staff

interaction and collaboration?

Agenda

Drivers of decentralization

Key questions

The evidentiary challenge

The MD Anderson project

Study data

Key findings

The AECOM Study

Six units

Three hospitals

Measurements:

- Functional space use

- Patient visibility

- Noise level

- Nurse perception of

work environment

Findings:

- Time spent on

telephone/ computer/

admin higher in

centralized

- Consultation/

interaction less

frequent on

decentralized

Centralized vs. Decentralized Nursing Stations: Effects on

Nurses’ Functional Use of Space and Work Environment

(Terri Zborowsky, et al.)

The Taiwan Study

Two units

Two hospitals

Measured:

- Staff interaction

- Patient falls

Findings:

- Less communication

in decentralized

model

- Less patient fall

events in

decentralized model

Impact of Architectural Design on Communication among

Hospital Staff. (Chai Hui Wang)

The WHR Study

Four units

One hospital

Measured:

- Patient satisfaction

- Nurse satisfaction

- Communication

- Walking distance

- Medical outcomes

- Organizational outcomes

Findings:

- Increase in patient

satisfaction

- No significant

differences in any

other parameters

The Effects of Nursing Unit Spatial Layout on Nursing

Team Communication Patterns, Quality of Care and

Patient Safety (Franklin Becker et al)

Agenda

Drivers of decentralization

Key questions

The evidentiary challenge

The MD Anderson project

Study data

Key findings

Location - the heart of the Texas Medical Center, Houston, TX

M.D. Anderson Cancer Center Background

• 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 Background

• 1998 – 1999

20% growth in patients

• 1999 – 2008

80% growth in patients

75% increase in employee

115% increase in research

revenue

• 2012 Projections

50% growth in patients

from 2006

M.D. Anderson Cancer Center Growth

Then and Now

THE BEFORE CONTEXT

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

Central Nursing

Station

Documentation

Station

Albert B. and Margaret M. Alkek Hospital

Albert B. and Margaret M. Alkek Hospital

Typical Amenities include:

• Murphy bed for family members

• TV/ Lodgenet

• Storage for luggage, clothing

Unit Configuration

Centralized work concept

Open medication prep

areas

Family waiting areas

small/lacking

Wayfinding challenges

THE AFTER CONTEXT

Expansion Project – Initiated in 2005

503,000 Square Feet

Added

11 Additional Floors

- 8 Inpatient Units

- Pharmacy

- Facilities support

- Mechanical / Electrical

Observation Deck

Current Operating Beds =

702

Future Operating Beds =

962

1. Need to maximize

the number and

size of patient

rooms per floor

using current

industry and best

practice standards

2. Need to improve

wayfinding for

families and

visitors

3. Need to add

family spaces &

amenities on floor

2 2

11

3

NN

Design Challenges – Patient/Family

1. Need to increase

access to nursing

stations

2. Need to improve

staff and patient

circulation

3. Need to improve

support and staff

areas

1 1

22

3 3

NN

Design Challenges – Staff

Key Goals and Objectives

The new Alkek patient units will be 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

Key Goals and Objectives

Additionally, key design elements should be

considered in relation to these guiding

principles:

Promote safety for patients

Enhance support for patients and their families,

recognizing that the family plays an active role in

the healing process

Meet/exceed the needs of the care givers -

integrate technology, maximize staff productivity,

increase time at the patient bedside, minimize

footsteps, enhance ergonomics

Design

Design-Build project McCarthy/HKS

Nursing Leadership Design Team 2006

Surveys on design topics- staff, physicians, caregivers,

patients

Focus Groups

- Medical Team Members

- Staff

- Patients & Family Members

Bulletins & Postings

SharePoint Site

Design Solutions - Patients/family

1. Increased footprint

to accommodate

more rooms per

floor

2. Improved

wayfinding on unit

3. More family

waiting

4. Added consult

room

1

11

1

33

22

44

NN

1. Improved staff

circulation within

core

2. Decentralized

staff stations at

patient rooms

3. Decentralized

meds and

equipment

3. Created team

rooms

1 1

22

3

3

3

3 4

44

4

Design Solutions - Staff

N

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

Inpatient Rooms

Room Zones

• Family Zone

- Sleep Sofa

- Additional Storage for Family

- Individual Television

• Patient Zone

- Flexible Acuity

- Desk Work Area

- Headwall Ergonomics

• Staff Zone

- Hand washing sink inside room

- Locked medication storage

- C5 mobile computer

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

Unit Staff Support Areas

Medication Rooms

• Locked medication rooms added to

each pod on the new units

• Addresses Joint Commission

standards for medication security

• Permits focused, uninterrupted

medication preparation by the

nursing staff

Team Station

• Fully outfitted admin area for Roving

Patient Service Coordinator/Staff

utilization

• Central Physiologic Monitoring

Team Room

Team Rooms

• Multi-purpose rooms located on each

pod to foster interdisciplinary

collaboration and teamwork

• MediaScape Smart Media

Collaboration Table from

Steelcase – data network

connections w/ ability to display

images from on-board desktop

computers or laptops.

• Web conferencing capable

• Educational Initiatives

• Glass walls of Team Rooms can

be reconfigured if future utilization

changes

STAFF AMENITIES – INPATIENT UNITS

• Staff Tranquility/Working Mother’s Room

• Locker Room ~ Staff Shower

• Staff Lounge

• Shared Multi-disciplinary Desks

• Conference Room

Staff Amenities

CLINICAL OPERATIONS

Unit Model

STAFFING

Staffing typically 2-3 patients/RN

Support staff: CNAs and PSCs

Clinical Nurse Leader, AD, ANMs

PATIENTS

Leukemia

Lymphoma

Stem Cell Transplant

“Mixed” hematology

Goals of the QI Project

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 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

Study Protocol

Pre Occupancy Data Collection

“Pre” Data Collection

January 18 – 31, 2011

G11 (Stem Cell Transplant) Alkek

Hospital

P6 (Hematology) Lutheran Pavilion

February 1 – 7, 2011

G9 East (Lymphoma Service) Alkek

Hospital

Written Surveys for 2 weeks – January 15

– 31.

Activation and Occupancy

“Bed shortage”/high census impacts

Phased occupancy

November 8, 2010 G16 G10W 26 beds to G16 48

beds

March 7, 2011 G17E: 12 beds open

March 14, 2011 G17W: 12 beds open

May 16, 2011 G15: G9E to G15

Post Occupancy Data Collection

“Post” Data Collection

September 8 – 22, 2011

G11 & G17 SW

September 26 – October 9, 2011

G15 & G17 SE

Written Surveys for 2 weeks – September 1 – 15

Activation and Occupancy

Activation

Management Team

Operations

PlanningMove

ManagementCommunications Training

Facility

Readiness

•Programs/Service

s

•Policies

•Systems/Procedu

res

•HR Functions

•Process Design

•Operating Budget

•Scheduling/

Sequencing

•Packing/

Labeling

•Department

Relocation

Management

•On-Going Staff/

Employee

Communication

•Opening Events

•Patient

Communication

•General Facility

Communications

•Operation

Simulations

•Training &

Orientation

•Master Training

Schedule

•Facility

Planning/

Development/

Construction

•Furniture/

Equipment/

Signage

•Facility

Completion/

Startup

Activation and Occupancy

Activation and Occupancy

Training and Education

Orientation methods

First new floor challenges

New workflow

New team members

Educational Resources

Educational Resources

• Short computer-based training modules developed to assist with

training utilizing Camtasia PowerPoint Voice Over Program

• Vocera

• Bedside supply cabinets

• Biohazard and linen pass-thru cabinets

• Team Rooms

• Multidisciplinary workrooms

• Medical team rounds

• Unit orientation

• Medication room

Operational Factors

Children’s Cancer Hospital Expansion needed temporary inpatient

unit.

Issues with showers and smoke dampers requiring moves of patients

floor to floor before full occupancy.

Increase in monitored beds-

decrease in ICU census

Operational Factors

Operating a 24 bed “unit” vs. 13 bed “pod”

Physician and medical team “centralized practice” concept

Staff rotations

Unit culture/staff roles

Post Occupancy Reviews

Staff feedback sessions August, 2011

Themes:

o “Unit Spread Out”, harder to find people/staff

o Patient assignments now need to consider

geography

o “View windows” yes or no?

o Pod vs. Unit function

o Like new medication room/system

o Team room use by medical staff

o Push button locks vs. badge

Agenda

Drivers of decentralization

Key questions

The evidentiary challenge

The MD Anderson project

Study data

Key findings

DATA TYPES

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

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

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

Agenda

Drivers of decentralization

Key questions

The evidentiary challenge

The MD Anderson project

Study data

Key findings

Identifying Patterns of Change

Multiple unit

comparison benefit

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

Performances change after intervention

The key question is consistency

Task Category: Documentation

15

17

19

21

23

25

27

29

31

33

Unit A Unit B Unit C

Before

After

Task Location: Nurse Station

25

27

29

31

33

35

37

39

41

43

45

Unit A Unit B Unit C

Before

After

Task Location: On The Unit

0

2

4

6

8

10

12

14

16

Unit A Unit B Unit C

Before

After

Task Location: Medication

0

2

4

6

8

10

12

14

Unit A Unit B Unit C

Before

After

Task Location: Supply Storage

0

0.5

1

1.5

2

2.5

Unit A Unit B Unit C

Before

After

Walking Distance

1.5

2

2.5

3

3.5

4

Unit A Unit B Unit C

Before

After

Documentation

15

17

19

21

23

25

27

29

31

33

Before After After New

Nurse Station

30

31

32

33

34

35

36

37

38

39

Before After After New

On The Unit

5

5.5

6

6.5

7

7.5

Before After After New

Medication

0

2

4

6

8

10

12

14

Before After After New

Supplies

0

0.5

1

1.5

2

2.5

Before After After New

Walking Distance

1.5

2

2.5

3

3.5

4

Before After After New

IMPLICATIONS

Implications

Documentation

increase

Is it because

documentation

stations/servers

are more

accessible in a

decentralized

configuration?

Implications

Nurse station

use decrease

Is it because the

need for

documenting

inside a nurse

station is

reduced?

Implications

On unit location

increase

Associated with

nurse station use

decrease?

Does this

represent an

increase in inter-

personnel

collaboration/

interaction.

Implications

Medication room

location

increase

Because of easier

access?

Supply storage

location

decrease

Are supplies

being delivered

inside patient

rooms?

Implications

Walking

distance

increase?

Counter intuitive

Does this

represent an

increase in inter-

personnel

collaboration/

interaction.

SUMMARY

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