The goals of many healthcare facility upgrades, expansions, and renovations in the Interior Health Authority of British Columbia, Canada, are much the same as elsewhere: to improve the quality and delivery of care, increase staff recruitment and retention, and optimize employee safety and productivity. Research has shown that changes to the physical environment and healthcare delivery, as well as large capital expenditures for healthcare facility construction, provide an opportunity to consider how evidence-based design can affect frontline staff and patients and improve overall healthcare quality.1 Research also has shown that incorporating a multidisciplinary team of planners, project managers, architects, ergonomists, hospital administrators, infection control specialists, maintenance staff, and frontline staff to work collaboratively will create a safe and supportive working environment for staff and a healing environment for patients.2

This process was used to upgrade and expand the Emergency, Ambulatory Care, Diagnostic Imaging, and Lobby/Reception departments within Cranbrook's East Kootenay Regional Hospital from April 2004 to January 2005, with construction set to begin this spring. The design process used focus group sessions and informal interviews, as well as work flow and task analysis, anthropometric data, human factors data, heuristic analysis, and mock-ups by the ergonomists, with all the resulting information evaluated by a core planning group consisting of the project planner and architect.

During the schematic design phase, all managers worked together to rough-block the design of each department, achieve agreement on appropriate department adjacencies, and define the overall shape and design of the hospital. The managers signed off on these drawings to indicate their agreement. Once the project moved into the design development phase, recommendations and design decisions were made at the departmental level. During this transition, the site administrator worked with the frontline staff to provide continuity among the departments and a comprehensive vision for the hospital.
Photo by Aaron Miller

Once the schematic drawings had been “signed off,” managers selected a “key” individual or individuals to represent the different areas of each department, to form a Design Development Team (DDT) for each department going through the construction process. Each DDT met with the architects, planners, and ergonomists every three weeks, and further shaped the design of the departments through the design development stage up to construction.

Of continuing value were the focus group sessions involving the members of each DDT, led by an architect who presented the drawings to the team members and rapidly drew new iterations as concepts were brought forward. During these sessions, the ergonomists provided recommendations and assisted staff with their contributions to the drawings, asking for their solutions to ergonomic concerns and other design problems, as well as for answers to various questions posed by the architects/planners. The ergonomists were also able to shadow these staff members throughout their work tasks and informally discuss their jobs, roles, and the sorts of design problems they encountered in their departments. The architect and planner were provided with the design implications of the information derived from staff. Revisions based on their input included changing orientations of workstations and locations of doors, modifying millwork heights, and offering specific equipment recommendations.

As an example of how the process worked, during an initial meeting with the DDT concerning the Emergency Department, the architect was having trouble deciding where the bedside monitors should be located. The DDT concluded that wall-mounted monitors worked best on the right side of the bed. The ergonomists confirmed this through an evaluation of the workspace using staff anthropometry, task analysis, and discussions with staff. The architect prepared his drawings accordingly.

Project Evaluation

Elements of this project were evaluated via a confidential, paper-based survey (using a five-point Likert scale) completed by frontline staff whose departments were being upgraded and expanded in November 2004. The purpose was to assess staff members' satisfaction with their current departments before the start of construction in terms of design and layout, how these affected their performance on the job both physically and psychologically, and how they influenced patient outcomes. The staff members also were asked their opinion of the participatory design process and how they felt about their involvement in it.

A total of 31 of 50 staff members from the Emergency, Diagnostic Imaging, and Admitting departments completed the questionnaire. When asked about the design of their current departments before the start of construction, more than 87% of staff said they did not like the existing design, with 74.2% feeling that their departments had a negative effect on job efficiency. Fifty-five percent felt that the existing design negatively affected patients and expressed concern about patient privacy and confidentiality issues. When examining the participatory process, 74.1% of staff stated that they were asked by their supervisor for input into the new design of their departments, and 80.7% liked being asked for their opinions. Seventy-one percent of staff felt that they were able to contribute to design changes for their departments, and 61.3% wanted even more of a say. (For more detailed data, see the table.)

Six months after the project's completion in 2006, staff will complete a matched-pair postconstruction questionnaire to determine how their perceptions changed because of the redesign and compare this with their matched preconstruction responses to evaluate the process.

Staff questionnaire findings

Disagree

Neutral

Agree

Hospital senior management has ensured that safety is considered in the new design of my department.

0.0%

42.9%

57.1%

Management has ensured that the new design captures staff and safety needs.

14.3%

35.7%

50.0%

My supervisor asked for my input into the design of my new department.

19.4%

6.5%

74.1%

was able to contribute to the design changes in my department.

19.3%

9.7%

71.0%

I liked being asked for my opinions for the new design of my department.

3.2%

16.1%

80.7%

I want more of a say into the design of my new department.

0.0%

38.7%

61.3%

Conclusion

This project has provided insight into the participatory design process and the elements required for employee acceptance of physical changes that can have psychological and organizational effects on the workplace. Input integrated from experienced frontline staff and management has provided valuable and unique feedback regarding how to best make physical changes to their departments. Although the study of this process is a work in progress, we can safely conclude that a participatory approach to the preconstruction phase of a community hospital redesign contributes to creating a healthy and efficient environment tailored to the needs and capabilities of workers. HD

References

  1. Ulrich R, Xiaobo Q, Zimring C, et al. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, Calif.: The Center for Health Design, September 2004.
  2. Canada Communicable Disease Report. Construction-related Nosocomial Infections in Patients in Health Care Facilities: Decreasing the Risk of Aspergillus, Legionella and Other Infections. Division of Nosocomial and Occupational Infections, Bureau of Infectious Diseases, Centre for Infectious Disease Prevention and Control, Population and Public Health Branch, Health Canada; Ottawa, Ont.; vol. 27S2, July 2001.