During my recent presentation, Keys to Designing Hospitals for Safety, Efficiency, and Patient Satisfaction at the 2016 Hospital Management Asia conference in Ho Chi Minh City, Vietnam, I identified efficiency as the second priority in designing hospitals.
Generally, many healthcare professionals negatively view the topic of efficiency as it is associated with staff reductions and “doing more with less”. I think it is more productive to think of it as “patient-centered efficiency” meaning adding value to the patient experience while reducing non-value added activities and expenses also known as waste. The concept of patient-centered efficiency can also be explained by asking oneself if patients want to:
- Wait for long periods of time to receive care, or
- Pay for unnecessary test, supplies or care, or
- Repeat or extend care due to lack of coordination?
Most answer no and, therefore, the focus of these recommendations are facility design strategies to increase patient-centered efficiency.
Reducing Variation. As many may be aware, reducing variation is a primary strategy of the LEAN philosophy. But, it can be taken one step further, meaning standardized work leads to standardized space. Significant efficiency can be achieved in hospitals by standardizing space particularly in repetitive spaces such as nursing units, clinic modules and in major rooms (e.g., operating rooms, ED bays, labor delivery recovery rooms, prep/recovery bays, etc.). Examples of this strategy include:
- Universal Rooms. Universal rooms are rooms designed with a common structure and infrastructure such that they can easily be customized for a particular use through the addition of equipment as opposed to major renovation. The use of universal rooms for patient rooms and similar spaces allows for flexibility and thereby facility efficiency. For example, a universal patient room can be converted to an ICU room by adding equipment and increasing the staffing level instead of undergoing expensive and time-consuming renovation. Other types of universal rooms include selected imaging rooms, operating rooms, delivery rooms and exam rooms.
- Standardized Support Spaces. Standardizing support spaces such as supply rooms ensures that each can be efficiently stocked with the same supply cart and in addition, staff can easily and consistently find what they are looking for. These standardized support spaces support standardized building systems and thereby reduce the time and money spent to support numerous unique rooms.
- Safer Medication Rooms. Since this strategy has such an important impact on safety it needs to be called out separately. Research has shown that standardizing the medication rooms throughout a facility improves staff efficiency as well as reduces medication errors by ensuring medications are consistently located in the same location.
Optimizing Nurse’s Time
There are several reasons that significant efficiencies can be achieved by optimizing nurse’s time. First, nurses, as the primary patient caregiver, typically represent the largest percentage of hospital employees, approximately 40% of the FTE’s. Nurses are highly educated and are projected to be in short supply throughout the world in the next decade. Even if the nurses are viewed as inexpensive labor in a particular country, that will change going forward as the demand increases. So, to deliver cost-effective care, it is important that nurse’s time be optimized.
Significant facility design strategies to optimize nurse’s time include:
- Decentralizing nurses and information. Decentralizing the nurse’s workstations proximate to the patient provides information at the point of care and increased visibility of the patients. Recent research has shown that decentralized nurse workstations result in fewer falls and medication errors. Although some caregivers may view this change negatively, research has shown that when compared to traditional inpatient units, units with decentralized nurse’s workstations had more communication between caregivers, more direct patient care by nurses and increased patient satisfaction. It should be noted that this strategy is applicable to the inpatient as well as outpatient areas of the hospital (e.g., emergency department, prep/recovery area, etc.)
- Decentralizing supplies to the point of care. By decentralizing supplies to the bedside or point of care, nurses spend less time hunting for and gathering supplies. Research has shown that nurses spend about 29% of their time walking, averaging 3.1 miles per shift. By decentralizing supplies to the bedside, facilities have found that nurse walking is reduced by approximately one mile per shift.
- Minimizing hand-offs. A major report on patient safety, “To Err is Human”, recommended that hospitals be designed to minimize handoffs as a way to reduce errors. Minimizing hand-offs also eliminates the nursing time spent moving patients from one area to another. Therefore, multifunctional spaces that eliminate the need to move patients should be incorporated into the planning of inpatient and outpatient spaces. Examples of this would include inpatient units designed to care for patients with several levels of acuity or preparatory and recovery bays designed to care for patients through all levels of recovery.
In summary, when planning a hospital the first priority should be patient safety and the second should be efficiency. But, in terms of efficiency, it is not enough just to consider efficient use of staff, materials, and space. Instead, efficiency should focus on how to deliver the highest quality of care to the patient by minimizing waste (e.g., waiting, materials, time, unnecessary transport, duplicative activities, etc.).