Today, we can find many inpatient room mock-ups that sparkle like a sports car rolling off a dealer’s lot. Undoubtedly, these mock-ups communicate a project milestone that translates into a fantastic marketing opportunity: The end users, owners, and designers have achieved consensus on design features and turned their vision into a reality to be shared with donors and the community.

However, what we do not see in a mock-up matters just as much-if not more. Ideally, a mock-up is one iteration during an ongoing cycle of validation and innovation¹. Also, mock-ups are the architectural equivalent of a highly interactive “learning laboratory” wherein participants manipulate a space and receive immediate feedback². In particular, mock-ups are spaces ideally suited to test, refine, and discover design ideas proven to benefit care delivery. However, like a stage without actors, a mock-up without a carefully orchestrated research process, setting, and work plan to back it will deliver a lackluster performance.

Plan of a Medical-Surgical Inpatient Room

The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at mgoodman@healthdesign.org.

Mock-up maximization

University Medical Center at Princeton’s (UMCP) decision to create a mock-up room for research-related purposes testifies to the Princeton Healthcare System’s ongoing commitment to excellence and its patients. The mock-up is a replica of the proposed standard medical-surgical inpatient room for the replacement hospital. The mock-up room’s purposes include:

• A space for testing design assumptions and their contribution to safe and efficient care delivery; and

• An opportunity to engage staff at all levels in the design of the medical-surgical inpatient room.

The decision was made to build the mock-up on an existing inpatient care unit. There were several advantages to the decision. These included:

• Rigorous experimentation: Controlled experiments during which staff would participate in scenarios (e.g., code blue) in the mock-up and matching inpatient rooms

• Reality: Scenarios conducted during routine care delivery on functioning patient care units

• Integrated delivery: An opportunity to have the mock-up inform much of the design process including placement of equipment and supplies inside the inpatient room

• Just-in-time research findings: The delivery of research findings in real-time for the design team’s benefit

• Convenience: Close proximity of the mock-up to study participants, equipment, and supplies advanced the work plan, prompted staff participation in the design, and elevated staff members’ excitement because they could see their vision becoming a reality.

A core team was assembled to plan the process for the Inpatient Room Mock-Up Research Project. The team consisted of hospital administration, multidisciplinary members of the patient care staff, trained researchers with expertise in the built environment and patient care, and research-based medical designers and planners. Then, the 13-member team completed a series of worksheet exercises during which they identified scenarios to test and prioritized topics for research. A central hypothesis was developed and used to assist the team members with prioritization of topics. The central hypothesis for the project is as follows: The design of the hospital room (mock-up), which includes its overall configuration, materials, equipment, and furnishings, will impact the occurrence of adverse events in the hospitalized patient including medication errors, hospital-acquired infections, and slips and falls. In addition, the room will impact the satisfaction of patients, their families, staff, and physicians.

Besides the traditional informal and detailed mock-ups, a third and unique type of mock-up was considered by the team. This mock-up could be converted to a fully functional inpatient room. It was then agreed that the mock-up room would evolve through three phases:

1. informal mock-up or learning laboratory;

2. semi-immersive with detailed mock-up;

3. fully functional inpatient mock-up room or “functional mock-up.”

The learning laboratory was completed in October, 2009. Currently in construction administration, the replacement hospital’s inpatient room design benefitted from several design implications resulting from research of the mock-up.

The following is a summary of the learning laboratory process and implications of the research results.

The learning laboratory: how it was done

Phase 1 was a learning laboratory during which staff took part in self-report and participatory design exercises. An informal mock-up constructed of foam-core and gypsum board represented the replacement hospital’s inpatient medical-surgical room and was constructed on an existing inpatient unit. During the learning laboratory, the mock-up served as a setting for research that validated innovative design and operational concepts like decentralized charting, decentralized supply and medication distribution, and patient-to-bathroom transfers.

The Learning Laboratory (above) Next to a Rendering of the Inpatient Room (right)

Hospital administration, registered nurses, physicians, nurse’s assistants, respiratory therapists, physical therapists, pharmacists, and case managers took part in sessions during which they toured the mock-up room and provided feedback with questionnaires and during focus groups. Each session lasted approximately 80 minutes in duration and was divided into two stages. During Stage 1 of the session, the participants were asked to walk around the mock-up room and fill out a questionnaire. However, the participants were not allowed to speak or gesture to each other. First, the questionnaire was used to collect the participants’ background information. Second, the questionnaire solicited the participants’ opinions about the room and activities within it such as acuity-adaptability, bathroom use, charting activities, space around the bed, approach to the bed, patient transfer, medication distribution, supplies, equipment, outlets, and usefulness of the mock-up. Third, the questionnaire solicited the participants’ opinions of the room’s impact on various outcomes related to safety, efficiency, and quality of care delivery. In total, 50 sessions were conducted.

Stage 2 of the session involved a work sheet with focus group discussion and direct manipulation of the mock-up room. Participants were allowed to interact with and consider other participants’ viewpoints when filling out the worksheet. The intent was to have results from the worksheet supplement results from the Stage 1 questionnaire by allowing participants to elaborate and deliberate various design solutions. In addition, participants were invited to test and illustrate their solutions during hands-on manipulation of the room furniture, bathroom design, and headwall outlet locations. The team found that the learning laboratory was crucial because design decisions made during initial user group meetings could not be fully understood and evaluated until experienced in three dimensions.

The innovation compass

Statistical analyses were conducted on responses from 51 nurses who work on UMCP medical-surgical units. The results from Stage 1 of the sessions had dramatic implications for the inpatient room’s design. Overall, the results targeted a specific design solution for common clinical problems, directed the team and users toward a set of design solution options from which they could choose the best, and encouraged the innovation of novel design concepts.

Staff Participating in Stage 2 of the Learning Laboratory

Overall, the research served as the team’s “innovation compass.” That is, research pointed the team in the right direction during design decision-making. For example, Stage 1 results from the learning laboratory indicated that the ability to concentrate was a primary concern of the nurses. In particular, the research revealed two pathways through which the nurses believed their ability to concentrate in a patient room designed like the mock-up room would impact the quality of patient care delivery at the patient bedside. First, the ability to concentrate and the number of months a nurse had worked at UMCP impacted the ease with which a nurse was able to locate necessary supplies and equipment. This, in turn, impacted the ease with which a nurse could administer medications or manipulate the IV at the patient bedside which, then, impacted the quality of patient care at the bedside. Second, the ability to concentrate impacted the ease with which a nurse could use the electric outlets and assist a bariatric patient during a bathroom transfer. These, in turn, impacted the number of slips and falls which, then, impacted the safety and quality of care. Field studies have demonstrated that centralized nursing stations and dedicated medication rooms in the nursing unit core can contribute to nurse distractions and interruptions because nurses have to leave inpatient rooms to accomplish care delivery3. Consequently, the team identified decentralized charting, supply, and medication distribution solutions that may facilitate patient care bedside and keep nurses close to their patients. These will be compared and tested in the semi-immersive and functional mock-up.

Additionally, the results from the Stage 1 analyses caused the team to closely examine the mock-up room’s bathroom configuration. Stage 2 results from the session were used to qualify the statistical findings. First, the findings directed the team’s attention to handrail innovations including a touch-sensitive, lighted handrail illustrated in Figure 4. Second, the bathroom was redesigned to allow for more space during dual assists with the patient-toilet transfers.

Data analysis of Stage 1 data revealed an unanticipated question: How “balanced” should the room’s balanced headwall be? Prior research has demonstrated that the side of the patient bed on which the IV is located is a strong indicator of which side of the patient bed a nurse will approach the patient4. Results revealed that nurses were more likely to hesitate over the correct headwall outlets to use during patient care when a patient’s IV pole was on the window-side of the bed. After a closer examination of the Stage 2 data, three balanced horizontal headwall configurations were identified as possible solutions. Results indicated the nurses would have benefited from a more detailed mock-up with structured scenarios, charting equipment, and hand sanitizers. In addition, results from the learning laboratory pinpointed design and operational directives that would guide scenarios conducted during the next semi-immersive phase. These included the patient-to-bathroom transfer, various charting solutions, and various nurse server configurations.

Phases II and III: semi-immersive and functional

Subsequent phases of the UMCP Inpatient Room Mock-Up Project will include Phase II with semi-immersion and a detailed mock-up and Phase III with a functional mock-up. The purpose of Phase II will be to study staff reactions to simulations presented in a realistic setting. Simulated scenarios will be evaluated for space efficiency, use of equipment, safety of care delivery, and caregiver satisfaction.

Phase III will take place in the functional mock-up room. A variety of methods will be utilized to gather information related to patient and staff experience in the room. Using a case comparative design, patients in the functional mock-up room will be matched with similar patients in other private rooms throughout the hospital. Data will be collected on standard clinical outcomes such as falls, medication errors, and infections. In addition, data will be collected on patient satisfaction with the room environment and care delivery.

A touch-sensitive lighted handrail is designed to prevent slips and falls when patients need to go to the bathroom

Leadership by innovation

At a time when so many of us wonder how research can contribute to the design process, the UMCP mock-up experiments are eye-opening. The project’s multiphased research design for objectively testing several design assumptions is, to the team’s knowledge, unprecedented.

The headwall option supported by research and selected by mock-up participants

UMCP’s commitment to the Inpatient Room Mock-Up Project will continue to garner benefits. The research will continue to deliver project-specific solutions that positively impact first costs and return-on-investment dollars. Other benefits will include marketing opportunities, UMCP’s association with innovative design, and a replacement hospital that is built to achieve superior clinical outcomes. Truly, if placed in the hands of a multidisciplinary research team, a mock-up becomes a sophisticated diagnostic tool that can prevent loss of time, potential waste, and dissatisfaction from having to work around a mistake for decades. This is a personalized prescription for facilities that leads to a positive prognosis. HD

Acknowledgment

The authors would like to thank the staff and physicians of UMCP who have taken part in the research. Also, the authors would like to thank contributing team members and colleagues including Barry Rabner, Carolynn Bitzer, Donna Covin, Jiyanti Ingle, Scott Laraus, Kathryn Ryan, Rebecca Almira, Natalia Lombardi, Jesse McCarter, Renaldo Pesson, Teresa Russo, Jason Zoss, Dina Battisto, Anjali Joseph, John Lorenz, Susan Grossinger, Chantal Pittman, and Ann Reo. You are leading the healthcare design industry with innovations in research, design, project management, and operations.

Nicholas Watkins, PhD, is Director of Research & Innovation and Ismini Naos is Senior Medical Planner at HOK. Susan Lorenz, RN, Dr.NP., CNAA, is Chief Nursing Officer at Princeton Healthcare System in Princeton, New Jersey. She is also the Vice-President of Patient Care Services at the University Medical Center at Princeton.

For more information, e-mail nick.watkins@hok.com.

References

1. Battisto D., Allison D., Mare G., & Herbert C. (2009). Critical analysis of two distinct patient room designs. Symposium conducted at the 2009 International Conference and Exhibition on Health Facility Planning, Design and Construction.
2. Watkins N., Myers D., & Villasante R. (2008). Mock-ups as “interactive laboratories”: Mixed methods research using inpatient room mock-ups. Health Environments Research & Design Journal.
3. Watkins N., Smith R., Rohrer K., & Stano J. (2009). Advancing Research in Practice: Validation of Innovative Design Strategies Throughout the Design Process. Symposium conducted at the 2009 International Conference and Exhibition on Health Facility Planning, Design and Construction.
4. Harvey T., Pati D., Evans J., & Cason C. (2009). Patient Safety – An empirical examination of the safety and efficiency implications of patient room handedness. American Society for Healthcare Engineering of the American Hospital Association. Symposium conducted at the 2009 International Conference and Exhibition on Health Facility Planning, Design and Construction.

Healthcare Design 2010 March;10(3):20-27