Research in Practice: Lesson 4

December 18, 2012
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A conceptual rendering of the clinician porch, as suggested by focus groups with nurses at the Miriam Hospital. Image courtesy of Knoll. This simulation was informed by onsite data collection of nurses’ travel patterns using PDAs. Image courtesy of Rapidmodeling Inc. and HOK. This theoretical design graphic comes from focus groups with Miriam Hospital nursing staff. The team translated nursing reactions into a hypothetical nursing design. The nurses felt an appropriately outfitted patient room with a “porch” could prevent searches for supplies and equipment while encouraging the nurses to conduct more activities at or near the patient bedside. Image courtesy of HOK. A data collector uses a tablet-based program to perform behavior observation and utilization studies. Image courtesy of HOK.
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The old adage that hindsight is 20/20 is often tinged with feelings of regret. In our last article, “Research in Practice: Lesson 3—Testing Innovation Through Simulations and Mock-ups,” we shared the importance of simulation techniques for visioning how designs will perform.

But a simulation without performance metrics collected from field research (actual walking distances, direct patient care time) is analogous to a cartoon—entertaining, but not reality. In this fourth article, we give a reason to celebrate and embrace hindsight with the post-occupancy evaluation (POE).


What is POE?
In practice, there are two types of POEs. One is more surface level and involves looking at a space and assessing whether it meets the specification and performance metrics for which it was designed following a facility’s occupation. The second, more progressive, definition is research-focused and looks beneath the surface to understand the impact of the built environment on users.

These more-rigorous evaluations can use advanced statistical methods to tease out the impacts of design interventions on outcomes such as occupant satisfaction, safety, health, and well-being.

POE evaluations are a type of field study, and field studies represent a paradox. On one hand, they’re limited in the amount of control the research team can have over the study’s variables. With true experiments, a researcher can theoretically control all variables, plan for the perfect sample size, and generalize findings. This level of control is difficult to achieve in a POE.

On the other hand, these POE limitations are also a blessing because we’re interested in how clinicians and patients will act in real-life settings. Properly conducted POEs have practical implications for solving complex design and operational problems for specific clients and afford exploration as the basis for innovation.

Each facility is different and may require a specific solution for a universal problem (for example, excessive walking by staff). Finally, with these studies, the design research net can be cast broadly at less cost and effort when compared to a true experiment.

What follows are some examples of POEs and their practical implications for inpatient unit layouts and decentralized care delivery. With these examples, we’ll illustrate the dynamics of a POE and the tangible benefits.


Destination bedside: Meaningful use at the Miriam Hospital
A Lifespan partner, The Miriam Hospital in Providence, R.I., has 247 inpatient adult medical-surgical beds and is recognized by the ANCC Magnet Recognition Program. Following the addition of a new inpatient floor incorporating decentralized nursing care (including dual-sided nurse servers with accessibility inside and outside of patient rooms, and workstations-on-wheels), the hospital conducted a POE to assess the impact of the design on health information technology, medical equipment, and supply usage. Results would guide design implications for future inpatient units proposed for the campus.

The work sampling data collected from the nurses through personal digital assistant (PDA) devices allowed researchers to analyze circulation patterns, congestion, and space utilization on participating units. The nurses also wore pedometers to keep track of walking distances. Questionnaires assessed the patient and staff experience. Adverse events data helped determine the impact of layout, furnishings, and cabinetry on patient-centered care.

Though the results of the POE validated a design innovation like the nurse servers, they also demonstrated some ongoing challenges. Nurses were using workstations-on-wheels in the hallways away from patients. Centralized medication cabinets at the main nurses’ station contributed to increased walking distances and concerns for patient safety. 

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