At Hospital Management Asia 2016, I was pleased to share a presentation on my top three facility planning priorities: safety, efficiency and patient satisfaction. The following narrative summarizes my first priority in facility planning, safety.
Safety has become a top initiative for many health care organizations since the Institute of Medicine (IOM) published its 1999 report To Err is Human: Building a Safer Health System. The industry was shocked when this report identified 44,000 to 98,000 preventable deaths annually due to medical errors. Many initially believed that the errors identified in the IOM report were the result of incompetent health care providers and high-risk procedures, but research showed that most errors were due to systems failures such as poor communication and numerous handoffs.
Many organizations responded by placing a high priority on developing a “culture of safety” meaning an environment that is not error free but instead is an atmosphere where care errors and close calls are reported without punishment and colleagues work together to prevent future errors.
Often, when referring to safety in the physical environment, initial thoughts are of details such as handrails and non-slip flooring, but there are opportunities to create a safer environment in the earlier phases of facility planning.
Reducing Patient Hand-Offs
The term “hand-off” refers to the transfer of responsibility for a patient from one caregiver to another and has become one of the top priorities in creating a safer health care environment. The Joint Commission’s 2007 Annual Report on Quality and Safety found that inadequate communication between health care providers or with family members was the root cause of over half of the serious adverse events in accredited hospitals.
Many organizations are addressing this issue by implementing a standard process for hand-offs, but facility planners are in a unique position to reduce the number of hand-offs. In the inpatient area, using acuity-adaptable rooms in their purest form – single rooms designed to accommodate a patient of any level of acuity – eliminates all transfers or hand-offs. For facilities that are not ready to fully implement the single room concept, grouping units by disease entity allows staff to coordinate care despite the need to transfer the patients between rooms on a multi-unit floor. In the ambulatory setting, hand-offs can be minimized by grouping related components of care in the same area, such as radiographic rooms within the ED and outpatient prep and recovery areas proximate to the surgery suite.
Addressing Handwashing and Medication Administration
One of the IOM’s four major recommendations related to the design of the workspace to mitigate errors was to address handwashing and medication administration first in redesign efforts. Fortunately, for facility planners, significant research has been conducted in both of these areas. Research has shown that it is not the number of handwashing sinks, but the location that has the largest impact on compliance. One study noted that 80 percent of health care providers felt that easy access to handwashing facilities would increase compliance. In the inpatient arena, handwashing sinks have proven most effective located adjacent to the open side of the door in inpatient rooms. In the outpatient setting, handwashing sinks should be placed near the patients. Recent research has found that alcohol-based rubs should be placed in similar locations, near the sink and entrance to room. Unfortunately most codes are not prescriptive about the optimal location of handwashing sinks. As a result, sinks exist, but often not in a location that promotes usage.
Research into the impact of facilities on medication administration has shown that frequent interruptions and distractions cause breaks in concentration and contribute to medication errors. Approximately 34 percent of medication errors take place during the nursing task of administering the drug. To limit distractions and interruptions, many newer systems have medications stored and dispensed at the bedside, and centralized medication areas are well lit, quiet, and free from unnecessary interruptions.
Preventing Patient Falls
In 2002, the National Quality Forum released a list of “never events,” errors that should never occur in a hospital. One of these events is death as a result of a patient fall. This list led the Centers for Medicare & Medicaid Services (CMS) to announce that they would stop paying for costs associated with eight of the “never events” as of October 2008 and other insurers are expected to follow.
Facility design has been shown to have a significant impact on mitigating falls when coupled with programs to identify and closely monitor patients at high risk for falls. Clarian Health Partners Comprehensive Cardiac Critical Care Unit with decentralized caregiver workstations reduced falls by 75 percent. Although there were many variables, these data indicated that by locating caregivers closer to the bedside, visual monitoring increased and falls were reduced. For facility planners, this research can be applied to the ambulatory care setting such as emergency departments and prep and recovery areas, with caregiver workstations decentralized proximate to the patients rather than large, central locations.
Reducing Nurse Fatigue
Fatigue, both physical and mental, among nurses has been identified as a contributor to errors. Although some fatigue is caused by the length of shifts or scheduling practices, a portion of it is related to nurses spending time and energy on tasks not directly related to monitoring patients and providing therapeutic care. Studies have shown that nurses currently spend approximately 35 percent of their time with patients and as much as 30 percent of their time walking up and down hallways in search of supplies, medications, or other health care providers.
One facility strategy designed to rectify this situation is decentralization of supplies, medications, and information to the bedside or point of care, most frequently achieved by patient supply cabinets or patient servers. Most patient servers are now mobile and include some form of computer. Research has shown that supplies at the bedside eliminated 700 to 800 trips to the supply room per week, which translates into 17.5 to 20 hours of nurses’ time that could be better spent on direct care activities.
Strategies the IOM study recommends to reduce mental fatigue include standardizing common work procedures, limiting the amount of reliance on worker memory, and decreasing interruptions and distractions. Facilities can address these issues by standardizing the locations of functions within the patient room as well as on the unit, decentralizing information to the bedside or point of care, and minimizing extraneous noise through acoustic treatments. As computers become smaller and more mobile, it will become easier to provide space and wireless infrastructure at the bedside.
Encouraging Patients as Safety Partners
The Joint Commission’s National Safety Goals encourage patients to be actively involved in their own care as a patient safety strategy. Research has shown that there are fewer adverse events and harmful errors if caregivers create a supportive and transparent environment that encourages patient involvement. From a facility planning perspective, caregivers need to be closer to the patients with space at the bedside or treatment site for caregiver interaction with the patient and family. Trends indicate that this is occurring in most newly constructed in-patient rooms, which are larger private rooms, and in ambulatory treatment areas such as EDs, which are being built as private rooms rather than bays.
Safety does not occur because of a single action but requires multiple, mutually reinforcing changes in the work environment to reduce errors and increase patient safety, according to the IOM report. Health care facility planners can join other high-risk industries that have made a commitment to a culture of safety and achieved substantially lower rates of errors. One note of caution is needed. As safety becomes a priority for organizations, many design features and concepts will be promoted as safe and error preventing; however, like research in medicine, facility planners must be vigilant about validating claims to ensure that money is not invested in ineffective solutions.
Global Health and Safety Initiative: http://www.globalhealthsafety.org/
JCAHO 2007 Report on quality and safety: http://www.jointcommission.org/assets/1/6/2007_Annual_Report.pdf
JCAHO 2009 National Patient Safety Goals: http://www.patientsafety.va.gov/docs/TIPS/TIPS_JanFeb09.pdf