Evidence-based design for building a World-Class Heart Hospital Part One
To realize their vision of becoming “world class,” The Ohio State University Medical Center (OSUMC) knew that “business as usual” would not apply. Building on the strategies set forth by its board in 1998, and on the heels of the completion of another campus facility called The Davis Heart and Lung Research Institute, OSUMC set out to create a distinct and dedicated heart hospital. To remain viable in this competitive market, OSUMC needed a differentiating edge, particularly because two other reputable healthcare providers in Columbus were already in the process of creating recognizable cardiac brands in the community with new facilities.
Being an academic medical center, OSUMC had always offered state-of-the-art, high-quality care based on research. Over time, however, cardiac services became scattered across the constantly growing campus and the center fell short on the quality-of-care experience—for the patient, family, staff, and physicians. Patients often made multiple trips to the hospital for diagnosis and treatment. Physician and staff efficiency was hindered, as nurses needed to accompany patients on multiple transfers, while physicians had to travel long distances between procedural and patient care areas. In fact, some portions of the cardiovascular (CV) care service line were separated by more than 1,200 feet and multiple elevator rides.
To effectively compete in its cardiac care marketplace, OSUMC envisioned designing a facility that would be flexible enough to provide leading-edge therapies—now and in the future—in a patient-centered environment that would enhance the overall healthcare experience. The facility would not only focus on patients and families, but also on staff and physician needs in an effort to recruit and retain the brightest and best clinicians.
One key to the design process was the creation of a team that would not only develop this vision. The team included OSUMC administration and facility planning teams; clinicians (physicians, nurses, and allied health professionals); and external expertise from Corazon, Inc.; DesignGroup Architects; and Hammel, Green, and Abrahamson, Inc. (HGA). Collaborating with numerous project stakeholders and focus groups, this multidisciplinary team integrated futuristic, innovative thinking to optimize operations, patient flow, and facility design to create a new model for excellence in cardiovascular care delivery—The Richard M. Ross Heart Hospital.
This article, part one of a two-part series, will address the designers and planners’ emphasis on the patient and family as key consumers.
The patient experience begins with the arrival sequence, and so the planning of the Ross Heart Hospital (RHH) placed added significance on the design of the surrounding campus. A space that had been surface parking was converted into a new arrival plaza, which improved wayfinding for the arriving visitor. This campus green transformed the entrance of the facility from a confusing sea of parking to a calming, beautiful, usable outdoor area connecting the visitor intuitively to OSUMC.
RHH's prominent atrium with its covered drop-off area functions as a beacon for arriving traffic. A 1,000-car attached garage offers convenient parking for patients and visitors. A contiguous caf and deli offer a more campus-like feel instead of the usual sterile hospital environment.
Upon entering RHH, the four-story, 3,500-square-foot atrium serves as an essential wayfinding device with its natural light and crossroads position. Visitors are welcomed by greeters and can easily locate the registration desk, elevators, and waiting areas for all floors. Views of the atrium and plaza are available from family waiting areas located on each floor. The atrium finishes contribute to its warm character and include maple paneling, terrazzo, carpeting, and fabric-covered acoustic panels. Overhead, suspended lighting supported on cables act as luminous “mobiles,” animating the space. The atrium's large expanse and natural light help reinforce feelings of security and reduce stress.
Acuity-Adaptable/Universal Bed Healthcare Delivery Model
Simply building a new facility would not be enough, the team realized—a change in care processes would have to accompany the changes in building structure and unit/facility design. In line with this, the traditional multiple-transfer setting—where patients were transported to different units based on the severity of their illnesses—was eliminated in favor of the acuity-adaptable/universal bed healthcare delivery concept. In this model, the required level of care is brought to patients while they remain in one room throughout their entire hospitalization (figure 1).
An acuity-adaptable/universal bed room at Richard M. Ross Heart Hospital demonstrating the progressive-care/low-acuity approach (A) and the intensive care/high-acuity approach (B). Courtesy of DesignGroup, Columbus, Ohio.
In addition to the high patient satisfaction discussed earlier, positive staff satisfaction has led to 2% RN turnover, an extremely low percentage. The acuity-adaptable/universal care delivery model has also contributed to an increased efficiency and cost savings by reducing lengths of stay, ranging from a 0.5-day reduction for cardiac catheterization procedural patients to a 1.55-day reduction for vascular surgery patients.
RHH opened as a 90-universal bed (UB) heart hospital in the fall of 2004. The design of the UB room at RHH accommodates the intensive care needs of acutely ill patients by providing a staff zone with adequate space for critical care equipment and rapid access to the patient in times of clinical instability. The placement of the bed within the room at an angle to the corridor also allows nurses to better observe patients during the acute period of their recovery. The moderate-size patient room—315 square feet, including the bathroom—strikes an appropriate balance between providing generous patient care and family space and keeping overall facility construction costs on-budget. The universal room's size adequately facilitates progressive patient recovery with a dedicated patient and family zone to encourage patient mobility and family visitation and participation in care.
Using a Mock-Up Room to Aid Design
In addition to having the core user group—including key hospital and physician leadership—set the vision and direction for the entire heart hospital, many members of the clinical staff were involved in design decisions. Although using a mock-up room is not a new concept, this process was invaluable in integrating the ideas of the bedside staff who would ultimately care for patients in these rooms on a daily basis. For example, the mock-up room was used to stage a “patient arrest” situation to demonstrate how the room would function at the most critical moment (figure 2).
OSUMC staff evaluating the Ross Heart Hospital universal bed mock-up room. Courtesy of DesignGroup, Columbus, Ohio.
The involvement of multiple staff members in the design process enhanced their buy-in and commitment to the universal bed concept. Through the mock-up process, the staff redesigned the room layout to enhance patient safety (figure 3). The patient bed was relocated adjacent to the bathroom to minimize travel distance and therefore reduce the potential for patient falls. The new angle of the bed, as mentioned, provided improved visual observation from the hallway.
Initial (A) and fi nal (B) layout of the Ross Heart Hospital's universal bed room. Courtesy of The Ohio State University Medical Center, Columbus, Ohio; DesignGroup, Columbus, Ohio, and Hammel, Green, and Abrahamson, Inc., Minneapolis.
Using the UB care-delivery model does not mean that any nurse can care for any cardiac patient. Nurses, like physicians, tend to practice in a specialty they enjoy. Nursing staff specializing in a certain clinical area are generally able to provide more efficient, higher-quality care and are able to troubleshoot more rapidly because of their expert knowledge in that specialty.
At RHH, like patients are aggregated on each of the three 30-bed patient care floors. One floor supports medical cardiology and vascular patients, another cares for cardiac surgery patients, and the third provides care for cardiac cath lab/electrophysiology patients. Recovering outpatient cardiac cath lab patients are intermingled with the inpatient population because their recover processes are clinically similar. Thus, instead of recovering in a busy, hectic, and crowded bay within a procedural recovery area, cardiac cath lab patients are able to enjoy the comforts of a universal room—a private room that can accommodate family members while offering a quiet, healing environment.
As noted, a key attribute of the UB care delivery model is the elimination of multiple patient transfers to various levels of care. An acuity-adaptable room significantly reduces such inefficiencies; it also enhances patient safety, since the level of care changes rather than the patient's location. In the typical setting, a patient transfer from an intensive care setting to a telemetry floor generally involves seven to nine staff members from various clinical and ancillary areas; it costs about $500 and takes an average of almost four hours. With this large number of staff involved, the potential for miscommunication is high and can result in medical errors. Reducing or eliminating transfers significantly decreases the potential for medication errors, lost belongings, and patient confusion or unease.
In addition, the RHH was designed to minimize time spent on transfers from procedural areas to patient rooms. The procedural areas are located on the same floor as the corresponding patient care area, creating mostly horizontal connections rather than elevator transports, thus saving time and reducing the costs associated with procedure-to-recovery transfers (figure 4).
The Ross Heart Hospital fourth fl oor patient care and procedural areas. Courtesy of The Ohio State University Medical Center, Columbus, Ohio; DesignGroup, Columbus, Ohio; and Hammel, Green, and Abrahamson, Inc., Minneapolis.
The universal rooms were also strategically designed to minimize transfers required for diagnostic tests. Rooms are large and private, and room-darkening window shades allow the performance of portable tests on the patient floors. A large number of echocardiograms and chest x-rays are now being done at bedside with the goal of increasing the portability of noninvasive testing modalities.
Standardized Facility Design
To increase the focus on patient safety, RHH's design was based on evidence supporting the reduction of medical errors through a standardized facility approach. The layouts of all three patient units are identical. Supplies are found in the same cabinets and drawers in all rooms, and equipment is placed in the same locations regardless of the patient unit or room. The goal was to standardize hospital layout so that nurses do not need to rely on memory for obtaining supplies when caring for a patient. Also, nurses who may need to assist on different floors are able to quickly orient to the unit and provide safe care.
Decentralized Nursing Documentation Stations
RHH elected to place nursing documentation stations—with access to electronic patient information, supplies, and medications—in the patient rooms themselves (figure 5). Surveys maintain that nurses often work from memory when patient records are not easily available, thus increasing the chance for medical error. The decentralized stations ensure that staff use the patients’ records with every care activity and eliminate the chaos and noise associated with a central nursing station.
Decentralized nursing documentation station in a universal room. Courtesy of DesignGroup, Columbus, Ohio.
This practice has been proven to reduce patient stress levels and facilitate healing. RHH patients state that although the unit is quite large, it is reasonably free of noise. Moreover, OSUMC believes that decentralized nursing documentation stations offering increased patient surveillance and nursing presence at the bedside have significantly contributed to a patient fall reduction.
RHH's UB design supports family involvement in the patient's care. Along with dedicated space for the family, the room includes a fold-out couch to allow family members to spend the night if the patient's condition permits. Wireless Internet service has been provided for family convenience, as well. After embracing the universal bed concept, RHH's culture has relaxed visiting hours for families throughout the day despite the intermingling of intensive care patients with progressive care patients, which is typical in a universal bed unit.
Emerging literature focuses on the impact of facility design on more than just providing a safe environment. Studies prove that a less-severe atmosphere can reduce patient stress and facilitate faster healing and wellness. The unit design at RHH includes soft, rounded corners, soothing wood tones, and colorful artwork, along with carefully managed hallway length. Curved hallways support the patient's perception of privacy by decreasing the crowded institutional feel of a large, 30-bed unit (figure 6). Within the rooms, a soothing environment was created via access to natural sunlight and views of the campus green—a “healing garden” concept on a much grander scale.
Softening the patient care unit with rounded hallways at the Ross Heart Hospital. Courtesy of DesignGroup, Columbus, Ohio.
Evidence-based design concepts were key in the creation of the world-class cardiovascular facility at RHH—an environment that supports a consumer-focused approach to care. Use of the universal bed care delivery model and healing environment, the promotion of patient safety, and the inclusion of family has led to a large increase in patient satisfaction and subsequent growth in OSUMC's cardiovascular market share. Patient satisfaction scores have increased to 85% versus the previous 76%, the highest of all OSUMC hospitals and the highest ever for cardiovascular patients within the system. HD
Part two of this article, to appear in a future issue ofHEALTHCARE DESIGN, will focus on the effects of facility design on staff and physician satisfaction.