Healthcare is blessed with many architects, builders, and owners’ representatives who specialize in hos-pital design and construction. And we have a heri-tage of management, board members, and employ-ees who are specially trained and experienced in healthcare delivery and management. Given all this assembled expertise, the findings of the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System, were especially motivating.

That report noted, you might recall, that for someone flying on a commercial airline, the probability of dying from a crash is 1 in 8,000,000 flights, compared with a probability of dying from a preventable medical error of 1 in 343 to 764 hospital admissions. Certainly, most providers and many friends with whom we have discussed patient safety said they have been touched personally by preventable medical errors, either directly or involving friends or family.

According to the report, the reason the medical error rate is so high is not the incompetence of those who provide care, but the design of the systems (or lack thereof) in which they work. At St. Joseph's Community Hospital of West Bend, Wisconsin, we asked ourselves: “Could our facility or the equipment and technology contained within cause preventable medical errors? Could the facility (and the equipment and technology associated with it) be designed to reduce preventable medical errors? Could facility design affect the systems of care contained within?”

The answers for St. Joseph's, a member of SynergyHealth, an organization that includes the West Bend Clinic and the SynergyHealth Foundation, were yes on all counts. However, little or no research appeared to be available on the topic; this was confirmed by safety experts, human-factors experts, architects, and other providers, all of whom affirmed our intuition. Most could give examples of how facility design affected their operations, but they could not provide a blueprint for designing out system failures or dangerous latent conditions.

Anticipating the design of a replacement hospital, St. Joseph's conducted a Learning Lab funded in part by the University of Minnesota's Carlson School of Management. Leaders in healthcare, patient safety, human behavior, hospital quality improvement and accreditation, pharmacy, nursing, and medicine, along with our design team of Gresham Smith and Partners, LLC (the architects), CG Schmidt Construction (general contractors), Ring & Du Chateau (mechanical, electrical, and plumbing engineers), and Ric Miller Construction/Consulting (the owner's representative) participated. The Learning Lab aimed to explore and make recommendations that would improve the preventable medical-error rate through facility design. The study group emerged with a top-10 list of recommendations for patient safety design, advice for designing around “precarious events,” and ways to change the traditional design process to emphasize safety concerns. The top-10 recommendations were:

  • Conduct Failure Mode and Effect Analysis (FMEA) at each design stage. This is an engineering testing approach in which the question is asked, “What would cause this system to fail and to what extent?” The system or facility design, then, is adapted accordingly.

  • Standardize design to the extent possible—e.g., having all patient rooms laid out in exactly the same way so that routines can be so well practiced that staff won't have to rely on memory or even to think about performing routine tasks correctly.

  • Involve patients/families in design planning.

  • Establish a checklist for current/future design, so that safety-enhancing factors can be easily focused upon and ensured.

  • Design so that critical medical information is always near the patient, thus avoiding its being lost or ignored because of time or distance factors.

  • Emphasize noise reduction to reduce fatigue and interruptions and increase patients’ sleep.

  • Design systems/spaces so that they can be readily adapted to future functional needs; this calls, for example, for planning adjacencies and elevators to allow for easy horizontal and/or vertical expansion.

  • Articulate a clear set of principles.

  • Begin equipment planning on Day 1 of the design process, rather than waiting until rooms/spaces have been designed first; this will account for the impact that equipment/technology can have on the inherent safety of a design.

  • Use mock-ups to investigate safety issues, starting on Day 1.

Other design principles were articulated at the Learning Lab, as well. For example, with good visibility of patients to staff, patient assessment is enhanced and necessary interventions are performed more rapidly; interior lighting needs the proper spectrum and in-tensity to expedite this. Automate where possible to reduce reliance on human memory. Design to minimize staff and patient fatigue. And design for vulnerable patients to enhance safety for all patients.

We also noted specific “precarious events” around which design decisions had to be made (as highlighted for frequency by the Joint Commission on Accreditation of Healthcare Organizations and the Veterans Administration National Patient Safety Center). These were:

  • Operative/postop complications and infections

  • Events relating to medication errors

  • Deaths of patients in restraints

  • Inpatient suicides

  • Transfusion-related events

  • Correct tube/correct connector/“correct hole” decisions

  • Patient falls

  • Deaths related to surgery at the wrong site

  • MRI hazards

The following are examples of how St. Joseph's has addressed some of these events. Because hand washing plays a major role in infection control, rooms at St. Joseph's are designed so that staff members must pass the sink when entering them, and patients are encouraged to make sure that staff wash their hands. Also, because most falls occur when patients are on their way from the bed to the bathroom, bathrooms are placed conveniently near the head of the bed, and guide rails are available the entire way. All rooms at the hospital are designed to prevent suicides (about half of which occur, according to research, in med/surg units, surprisingly enough) with the use of breakaway ceiling fixtures, for instance.

As a result of the Learning Lab, we recommended changes to the traditional design process—specifically:

  • RFPs to include questions relating specifically to patient-safety-related design and construction experience;

  • discussion of safety issues during all interviews with the design team;

  • education of the design team concerning the top-10 patient-safety design recommendations, other design principles, and considerations regarding precarious events, as mentioned above;

  • preproject retreats to develop design concepts for implementing the recommendations;

  • a technology fair, highlighting technologies that might help maximize patient safety;

  • as recommended above, use of equipment planning and safety-related mock-ups, starting on Day 1; and

  • implementation of FMEA at every stage of the design process.

One of our preconditions for working with the design team named above was that they be committed to maximizing patient safety and willing to adapt and adjust their processes to this end. We knew this would be critical to our success in achieving a safer facility.

Tom Wallen, AIA, director of business development at Gresham Smith and Partners and principal architect in charge of our project, exemplified this commitment. When Gresham Smith first started their involvement, they were concerned that making safety such a priority might hinder the design process, but they soon found otherwise. Says Wallen, “We found that the focus on safety in design also led to the creation of healing environments, efficient spaces and processes and, ultimately, a higher-quality facility.”

One example he cites was our implementation of the principle of standardization. Researchers state that to achieve a high level of error reduction or quality care, standardization of design is crit-ical. Wallen recognized this and said we should “take advantage of true standardization (identical and replicated) that we know will result in safer care. It will also result in the potential to receive more cost-effective construction bids.”

Structurally designing a hospital so that the rooms are truly standardized (i.e., not back-to-back, mirrored image, or different sizes) is challenging; it means, for one thing, having to forego individual preferences of staff members in specific units (see Figures 1 and 2 for examples of standardized layouts).

Even more difficult, however, is the fact that safety design principles such as standardization occasionally conflict with other principles, requiring that the standards be prioritized. An example of this was our ICU design—essentially, a semicircle around a nursing station in which, if the rooms are standardized, patient visibility diminishes as one's view moves toward the apex of the semicircle. The nurses felt that patient visibility took priority over standardization, and this required us to “flip” the design of the rooms near the apex so that patients’ heads were al-ways clearly visible.

Another example of the strong involvement of safety considerations in our design was the result of FMEAs that we conducted on the planned adjacencies of various clinical services. One original plan had the ER and radiology located next to each other on one floor and the ICU located on the floor above. The FMEA disclosed the risk involved in having the ICU nurse ride down the elevator to pick up a patient, take him/her to radiology, and then back up the elevator to the ICU. The nurse would be temporarily absent from her unit duties, or an elevator could malfunction; in either case, an ICU patient could be placed in mortal danger. All the units ended up as adjacencies on the same floor (Figure 3).

A word on FMEAs: Because the FMEA process for assessing facility design is different from the one used in assessing processes, facility-related FMEAs are called d(design)-FMEAs, while FMEAs to assess processes are called p(process)-FMEAs. Useful though they are, FMEAs of both types can have their weaknesses; e.g., participants can slant an FMEA toward their own points of view. That is why architects and other design team members must be properly educated about FMEA to bring objectivity to the process.

As already indicated, FMEAs, when used properly, are powerful tools. Gresham Smith and Partners, for example, have changed their design process to include FMEAs as part of their hospital design proposals because of what they learned about their importance in analyzing failure possibilities and their impact on patient safety.

Humans will err—that is a certainty. It is the designers’ and design team's responsibility, however, to create facilities that will minimize that possibility. Tom Wallen says he now believes that “architects can change the level of safety in the healthcare system through design, by partnering on this with the organizations they serve.” And St. Joseph's Community Hospital, for its part, believes that our new facility design will, in fact, produce a safer, higher-quality institution for the patients served. HD

CEO of SynergyHealth, Inc., and St. Joseph's Community Hospital, West Bend, Wisconsin.