Presbyterian Healthcare Services of New Mexico is in the process of designing a $205 million Greenfield campus. As a member of The Center for Health Design's Pebble Project Research Initiative, it is in keeping that the medical center plans are based on Lean principles and evidence-based healthcare design research. Prior to finalizing the schematic design, Presbyterian chose to invest in rapid prototype mockups for seven types of rooms: operating room, emergency department, medical/surgical, critical care, intensive care, LDRP, neonatal intensive care, and physician office practice exam room. Rapid prototyping has long been used in automotive, electronics, and other industries. Design firms such as IDEO in Palo Alto, California, were among the first to successfully apply the technique to healthcare.

Rapid prototype mock-up rooms are similar to scale model stage sets; the room includes some of the equipment or furnishings that will be used in the room (e.g., isolettes, beds, and furnishings) but everything else in the room is created from heavy cardboard material, which is easily movable to different locations.

The architectural firm Dekker/Perich/Sabatini (DPS) created the patient-care room schematics and directed construction of the cardboard replications. The cost of materials for the seven rooms came to less than $10,000. Ted Kostranchuk, an associate at DPS, notes, “Being able to experience space in lieu of seeing lines on an architectural plan allows the observer to move through the space, challenge the design, and then make the necessary modifications to arrive at a desired outcome.”

The overarching goal of the mock-ups at Presbyterian was to invite medical and clinical staff to critically assess the functionality, efficiency, and safety of the rooms from both a staff and patient viewpoint.

The interactive capability of the mock-up and the role-playing opportunities it presents were extolled by Dawn Reynaud, RNC, permanent charge nurse, maternal special care. “It's always been difficult to see architectural plans and then try to envision whether our patients' families will feel comfortable or whether the nursing staff can effectively care for patients in the space provided,” Reynaud says. “After the hospital is built, the rooms are completed, and the first patients are being cared for, staff members typically say, ‘Wouldn't it have been nice to have additional space here, or the sink located there?’ Using a mock, cardboard room to scale, the doctors, nurses, and ancillary staff who will be using the LDRPs were able to suggest changes before the plans were finalized. What a novel idea. Plus, hospital staff was invited to view the final mock room to make last minute changes, so that the new hospital will have the perfect LDRP.”

Women's Services Medical Director Krista Willis, MD, stressed the efficiencies that the process will permit over the current facility: “With this design, each room will no longer have to be completely equipped. There will be less movement of the patient.”

The rapid prototype mock-up project was spearheaded and directed by the Himwich Group (THG), a national healthcare consulting firm located in Albuquerque. Diane Bruno Himwich, MS, a principal with THG, led small groups in staged clinical scenarios that tested the room requirements for the provision of routine care as well as during an emergency situation. Forty interdisciplinary groups participated over the course of the two weeks that the mock-up rooms were in place. A measurement tool capable of capturing opinions was created and analyzed by THG consultant Beth Hamilton, PhD.

The following is a sampling of issues that might not have been addressed except for the rapid prototype mock-up:

Operating room. The OR table orientation and the need to have the room flexible and adaptable to the needs of a variety of surgical teams; type and location of the waste disposal system; the location, shape, size, and composition of the nursing control desk; the number and location of light switches and electrical sockets.

Physician office practice exam room. Size and layout of the room such that it can accommodate patients in wheelchairs and walkers; orientation of the exam table so that the physician can approach the patient from the patient's right side; exam table capable of accommodating those who weigh 400 pounds or more and/or those in wheelchairs.

Critical care patient room. Key placement of the handwashing sink and gel sanitation dispensers to support usage for hand hygiene; headwall sockets located at an ideal height so that staff can easily plug in oxygen and other gases; ceiling lifts for patients, especially those who are heavier than the average, can be easily moved; the need to have all switches and sockets covered with a material for easy cleaning and disinfection.

Medical/surgical patient room (figure 1). Clinical work space, large enough to set up for a procedure or prepare medications; writing space and charting area that encourage interaction with the patient during documentation; enough storage for frequently accessed equipment and supplies; the patient bathroom was missing a pull down or molded shower seat and a vertical grab bar between the commode and the sink.

Medical/surgical patient room mock-up

Emergency room (figure 2). The final rendition of the mocked-up headwall, which featured sockets on both the right and the left, was deemed superior to that currently in use because the caregiver did not have to reach over the patient to hook equipment into the headwall.

Emergency room treatment space mock-up

LDRP room (figure 3). A short wall between the mother's bed and the placement of the baby warmer was eliminated because it prevented the mother from seeing her baby; the wardrobe for family was deemed too large and an alternative was suggested.

LDRP room mock-up

Neonatal Intensive Care (figure 4). The door opening should be close to the hand-washing sink instead of near the bed to support hygeine; the work-space area was drastically changed with counters on either side of the room and the inclusion of a locked cabinet; sharps boxes on two walls; foot operated sink in a completely different location; the headwall needed a height adjustment so that providers could more easily insert oxygen and air hoses.

Private Neonatal Intensive Care room headwall mock-up

Presbyterian's Senior Vice-President for Performance Acceleration Joe Calvaruso had high praise for the exercise: “The rapid prototyping process was extremely valuable because it allowed us to role-play with several people in a setting that encouraged participants to make changes in the moment and experience the effect of those changes in real time. Everyone was comfortable making suggestions because they felt that we were early enough in the process to have their recommendations actually reflected in the design. Several frustrations of existing rooms and units were expressed and we learned from them. The redesign will greatly enhance caregiver and patient satisfaction, productivity, and safety.”

While it was not a primary goal of the mock-up rooms, staff satisfaction was dramatically affected by participation in the exercises. Ninety-seven percent of those who participated deemed the exercise “effective” and the majority wrote comments on their data forms expressing gratitude for being included in the process of designing their own work space.

During the process, several participants suggested innovations that may be considered as well. A small sampling of these includes oxygen ports in bathrooms for oxygen dependent patients, height-adjustable toilets, and an easily sanitized privacy screen that folds back, out of the way, thus providing privacy when needed and avoiding the infection control issues related to fabric privacy curtains.

The overall impact of the rapid prototype mock-up at Presbyterian is neatly summed up by Administrative Director of Community Relations Kim Hedrick: “Presbyterian's investment in seven mock-up rooms with more than 40 groups interacting directly with our clinical consultants and architects on how day-to-day operations occur in these rooms is invaluable to understanding square footage and equipment needs as well as placement of the tools staff use most often. The lessons learned by having nurses, physicians, maintenance, housekeeping, and others walk through various clinical scenarios in the rooms has helped us prioritize staff and patient needs, which should eliminate change orders at the end of the project.”

Presbyterian's positive experience has shown the value of including rapid prototype mock-ups when doing new construction or renovation. With appropriately guided exercises, mock-ups can resolve flow issues, allow for the assessment of operational and staffing pitfalls, and provide for clinical simulations of both routine and emergent care.

Presbyterian also learned that mock-ups are fun. Rapid prototype rooms are the grown-up equivalent of play. As Ted Kostranchuk, an Associate at DPS, notes, “It reminded me of constructing and flying model airplanes as a child. In reality I knew they were no more than fragile pieces of balsa and tissue paper, but during flight, nothing could have been more real.” HD

References

  1. Kelley T. The Ten Faces of Innovation. Doubleday: 2005.
  2. Kelley T. The Art of Innovation: Lessons in Creativity from IDEO, America's Leading Design Firm. London:Profile Books, 2004.
  3. Reiling J. Safe by Design: Designing Safety in Health Care Facilities, Processes and Culture. JCR:Oak Park, IL, 2007.

Sidebar

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.