Just as medicine has increasingly moved toward evidence-based approaches where clinical decisions are informed by research, healthcare design worldwide is progressively using rigorous research that links a hospital's physical environment to healthcare outcomes. Although Canada's healthcare model is radically different than that of the United States, a unifying factor appears to be a commitment to evidence-based design. One such example is Pebble Partner Trillium Health Centre, which has recently opened a $100-million, 190-bed inpatient wing.
Built on time and on budget, the seven-story wing is a result of everything Trillium has learned about evidence-based, cost-effective, patient-friendly design. Many of the design features in the wing (e.g., decentralized nursing, patient room design, wireless technology) will be evaluated for their effect on patient and workplace safety, patient outcomes, cost effectiveness, staff impact, and overall quality of care. Planned with a 50-year window to the future, the new wing demonstrates how design blending physical space, models of care, and leading-edge technology can positively transform the patient and staff experience, while also anticipating future community needs.
Realizing a vision
The community-based tertiary care hospital initially faced significant challenges in seeking government funding approval for the design, which integrated features well beyond accepted national standards (e.g., 50% private rooms). Unlike the United States, where private rooms are increasingly accepted as the norm, regulations in Canada have only recently changed, and each Province sets its own design standards. It wasn't until 2008 that an increase in the percentage of private rooms (80%) was included in Ontario regulations. Up until then, in Ontario and most of Canada, the norm was a mix of quads (wards) and semiprivate accommodations with some private rooms.
Making the team's vision a reality involved capital planning with the Ontario Ministry of Health and Long-Term Care, a multistep review process that includes initial approval of a functional plan, followed by a review of sketch plans, which then leads into drawings and specifications. Once these are approved, the hospital can then go to tender.
Given their approach to the wing's inpatient room design, the design team built a full-scale model of the semiprivate room in a nearby warehouse, affording government officials, patients, staff, and accessibility organizations the opportunity to “live” the design firsthand.
Other significant negotiating factors following approvals that were in keeping with best practices included a request to incorporate 50% private rooms, which at the time, was above accepted standards in Canada. So too was the hospital's proactive infection control request for the installation of handwashing sinks for every patient bed backed by research that shows that well-designed hospitals curb infection.
Trillium leveraged documentation from the American Institute of Architects to substantiate its desire for patient beds with single-point-of-entry access, citing proven benefits that included reduced medication errors and optimum patient/visitor flow.
Among the key selling points was the building's longer-term adaptability to changing standards. The structure features a clear span from the center core to the outside walls that gives the hospital the flexibility to adapt and change configuration of the building in the future without encountering significant structural changes.
The eco-friendly design also maximizes the benefits of natural light and uses shading technology to reduce the amount of heat absorption in the summer and maximize incoming sunlight in the winter.
While traditional hospital buildings use punched-window construction, the new wing incorporates a high-efficiency, triple-glazed curtainwall system, which is relatively new to hospitals in Canada. While this meant an incremental increase in capital costs, the hospital emphasized that this money would be recovered through utility savings.
Embracing the patient perspective
There's little doubt that evidence-based design played a critical role in obtaining the necessary approvals to move forward with these precedent-setting concepts. In 2000, Trillium Health Centre's interdisciplinary inpatient design team established the vision for future inpatient care by applying four key principles:
Patients will be older and more complex
Staff will be older and ergonomic considerations will be critical for staff satisfaction
A quiet, soothing, homelike environment is desired
Technology will be evident at the bedside
The team wanted to bring staff closer to the patients and to enable patients to have more control within their own environment. Patient and staff safety was a critical factor. The design also had to be flexible enough to accommodate changing community health needs over the next five decades.
Susan Black, principal architect of Perkins Eastman Black Architects and designer (in joint venture with Parkin Architects) translated the team's vision to paper, incorporating basic principles of sustainable design with patients', doctors', and nurses' input.
Designed to promote healing, improve patient outcomes, and reduce patient stress and anxiety, each of the new wing's 36-bed units features three 12-bed clusters housing six private rooms, one semiprivate room, and one ward room (four beds). With flexibility built in, the ward room can quickly be converted to a semiprivate room with the pull of a movable wall (figure 1).
Central to the wing's design is a two-bed inpatient room configuration that allows for maximum privacy, confidentiality, and safety regardless of what type of room a patient is in. Each patient bed is visible from the corridor and can be accessed through its own door, has its own handwashing sink, offers a separate entrance to the shared barrier-free washroom and has its own picture window offering expansive views of the outdoors (figure 2).
The room design allows for ease of maneuverability when transferring patients onto stretchers or into wheelchairs, and provides ample space for visitors. Given the 45-degree angle of the patient beds, patients in semiprivate rooms can't see one another, and additional privacy can be achieved with the pull of a curtain (figure 3).
The use of abundant artwork, natural light, and vivid colors throughout the units attempts to relieve the sterile feel of traditional hospital spaces. Nine-foot-high corridor ceilings and designated alcoves for the storage of supplies and equipment keep the hallways free of clutter.
Quiet rooms for families, a nutrition station, a patient lounge, and a therapy/education room are available on every floor. Televisions are available at every bedside and internet access will soon be available.
Noisy overhead pagers have been replaced with wireless nurse call devices connecting patients directly with their attending nurse and improving responsiveness to patient requests.
Optimizing healthy workplaces
Poorly designed workspaces often lead to inefficient patient care, and several correlations link the work environment with nurse satisfaction. In hospitals, where nurses experience job satisfaction, the patient outcomes are often positive (Hendrich A. Hospital Work Environments: Implications for Nursing Practice and Patient Care Quality, 2006).
The new wing's decentralized care model addresses process inefficiencies by offering three main care stations serving 12 beds. These are further complemented by satellite stations for every four beds, bringing care providers closer to their patients, reducing travel times (by as much as 50%), maximizing mobility of clinical and nonclinical teams, and increasing nursing time at the bedside. Every four beds has dedicated access to frequently used supplies and a medication cart.
The availability of wireless nurse call devices allow nurses to not only connect with patients in a timely manner, but also with physicians and other members of the team.
Other electronic enablers such as eWhiteboards, Workstations on Wheels (WOWs), tablets, and touchscreens mean care providers can access vital information, test results, and alerts from anywhere on the unit at any given time, allowing for more timely assessments and responses to patient care needs.
“All the technologies employed put the needs of patients and staff first,” says Patti Cochrane, vice-president, Patient Services and Quality, Trillium Health Centre. “We're not interested in bells and whistles, but in how technology can improve the human experience.”
The ergonomically designed infrastructure includes convenient waist-height access to devices and equipment including oxygen and medical gases at the bedside. Dedicated rooms on each unit are also equipped with ceiling lifts to support the safe movement of patients.
Each unit also features a staff lounge, conference room, and team room.
Trillium Health Centre expects to see reduced medication errors, a reduction in fall rates, shortened lengths of stay, reduced noise levels, improved turnaround response to call bells, reduced staff fatigue, fewer staff injuries, and better overall satisfaction levels among care providers, patients, and families.
Starting in September 2009, Trillium Health Centre will measure a number of outcomes in the new wing including:
Patient outcomes-patient satisfaction, patient safety (falls, medication errors, nosocomial infections), medication use
Staff outcomes-travel distances, nursing satisfaction, Occupational Health & Safety indicators, workflow efficiencies
Efficiencies-length of stay, internal patient transfers, response time, bed turnaround times, time required to assess data
Janet Davidson, president and CEO, Trillium Health Centre says that the organization's hope is to inspire hospital planners and architects everywhere by transforming the way healthcare is delivered.
“With this project, we wanted to elevate the environment for healthcare,” she says. HD
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 firstname.lastname@example.org.Healthcare Design 2009 October;9(10):10-15