Designing smart

February 1, 2011 by Debajyoti Pati, PHD, FIIA, LEED AP and Angela Lee, AIA, ACHA
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Can larger inpatient bed units and the efficient use of nursing time go hand in hand? A recent postoccupancy evaluation of two HKS-designed inpatient units suggests so

Arriving at the right unit size is a challenge. A greater number of beds in a unit improves staffing efficiencies. However, as hospitals transitioned to all single-patient rooms (2006 guidelines mandate private rooms), a greater number of beds has translated to larger floor plates, greater distances between destinations, and more nursing time wasted in nonproductive tasks. A recent archival study by Kurt Salmon Associates found that acute care units have increased in floor area by 118% over the past 20 years.

A mismatch between the physical transformation of inpatient units over time and the clinical processes that it supports has contributed to the nonproductive use of nursing time. In a 36-hospital time-motion study, a team from Ascension Health, Kaiser Permanente, and Purdue University found that the average total walking conducted by nurses ranges between 2.4 and 3.4 miles on a 10-hour day shift, and 1.3 and 3.3 miles on a 10-hour night shift. That translates to a higher extreme of about 4 miles on a 12-hour shift. These figures confirm some other studies that found similar long walking time for nurses.

Dr. Debajyoti Pati, FIIA, LEED AP
Dr. Debajyoti Pati, FIIA, LEED AP

Why is nurse walking time an issue? One perspective pertains to individual performance. With the median age of American nurses at 53 years old, one could argue that long walking distances, along with the mentally and physically demanding work that nurses conduct, could impact their stress, fatigue, and alertness-and, therefore, their individual performance.
Roomside charting alcove at Texoma Medical Center
Blake Marvin/HKS, Inc.

Roomside charting alcove at Texoma Medical Center

A second perspective relates to system efficiency, where unnecessary walking can be considered as waste. It is a type of nonproductive use of nurses' time, which is better utilized at bedside or other care tasks that add value to the services rendered. Distance walked and time spent in walking is considered an important metric in Lean operations design and intervention. Furthermore, the extensive time spent walking goes against the prevailing notion of patient-centric care, as it takes the caregivers away from the patient for prolonged periods of time.

As a result, many facilities are considering smaller units (such as 24 beds instead of 36 beds) to reduce nurse walking distance. That, in turn, poses the challenge of optimizing staffing efficiencies as well as maintaining an adequate level of peer support during night shifts.

The Summerlin and Texoma inpatient units

HKS designers confronted these challenges in the design of a bed tower addition at Las Vegas's Summerlin Hospital and at Texoma Medical Center in Denison, Texas, using four guiding principles:

  1. Proximity of services;

  2. Amenities for care;

  3. Decentralized nurses' station; and

  4. Computer logistics.

The underlying logic was that by focusing on the efficiency of flow, one can focus on patient-centric care and supply nurses everything they need without walking long distances. Both units were large-34 to 36 beds in size. It was hypothesized that by optimizing flow and reducing potential waste, the large unit would not result in walking distances that are substantially higher than the national benchmark. Similarly, it was hypothesized that how nurses spend their time would not constitute an outlier. In other words, if a unit is designed properly, a nurse will walk 2.4 to 3.4 miles (the latest data from the 36-hospital study) in a 10-hour shift, irrespective of the unit size.

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