Designing for safety
Nine miles on foot; constant alertness, concentration, and preparedness for the unexpected; endurance and determination to fight fatigue; and ability to handle demanding terrain and any emergency that might arise. These could be the challenges facing a competitive athlete, police officer, or rescue pilot, but, in fact, they represent the typical eight-hour shift of a pediatric nurse.
A defining moment in the planning of the new University of Minnesota Amplatz Children's Hospital came when a study of nursing staff travel patterns revealed the startling nine-mile distance most nurses walked during an average shift. Applying principles of Lean production, safety-focused, and evidence-based design, the collaborative project team of hospital, architects, and safety-design experts created a physical and operational model for the new inpatient units that, among numerous improvements, reduces the average nine miles spent on foot to five. The dramatic reduction has potential life-or-death implications: less fatigue for nurses, more time spent providing direct value to patients, and improved safety in the healthcare environment. The successful implementation of design principles that are focused on safety and efficiency offers lessons for other healthcare organizations.
For the past decade, calls to action to improve hospital safety have been loud and clear. The Institute of Medicine's seminal report in 1999, To Err is Human: Building a Safe Health System, sounded an alarm to reduce preventable medical errors. The work of the Institute for Healthcare Improvement, such as Donald M. Berwick's Advocate for Evidence-Based Health System Reform, and collaborations of the Institute for Clinical Systems Improvement, to name a few, have focused on quality improvement in healthcare.
But, as the design of the new children's hospital demonstrates, there still is room to innovate. How can design support safety in the healthcare environment? What safety-oriented changes can be initiated to improve the quality of existing operations? And what are the trade-offs and lessons learned in the process?
Fairview Health Services, owner of Amplatz, imposed its own broader call for action as it deepened its commitment to safety and its drive for continual improvement. As an academic medical center and the oldest and largest children's hospital in the state of Minnesota, the institution sought to relocate from a hospital-within-a-hospital model and create an independent, distinct children's facility (see sidebar #1). The new hospital is designed specifically to create the best environment in which to provide and receive children's healthcare. From day one, patient and staff safety drove the project's design. The initiative and methodology employed at Amplatz exemplify an approach to designing for safety that benefits any hospital facility.
Set guiding principles from the start: The best is the safest
Amplatz understood that an expectation of safety is inherent in their vision to create an optimal children's healthcare environment. It is important that the new facility not only be attractive and welcoming for kids and their families, but also achieves the highest possible level of safety.
At the outset of the project, hospital leaders established guiding principles that were used to direct the planning, design, and construction of the new children's hospital. The principles emphasized achieving a safe, efficient, and high-quality environment by:
optimizing the patient and family experience through a plan and design that would foster patient and family-centered care;
incorporating Lean principles that have successfully been used in other industries;
maximizing light and visibility to facilitate healing, patient, family, and staff safety, and wayfinding;
designing to facilitate collaboration and the education of the next generation of healthcare professionals;
promoting the integration of patient care, education, and research; and
utilizing an on-stage/off-stage design concept.
Assemble collaborative expertise: There's safety in numbers
With these principles at the forefront, Amplatz assembled a team of specialists to collaborate with their own staff and user representatives in the planning and design of the new facility.
National healthcare architects Tsoi/Kobus & Associates (TK&A) of Cambridge, Massachusetts, were selected early on to lead the design team as design and executive architect. Supporting Fairview Amplatz's commitment to design excellence, TK&A drew on their experience designing projects at major academic pediatric medical centers including Children's Hospital Boston and The Children's Hospital of Philadelphia. To enhance the programming process, TK&A brought on board national pediatric expert and frequent collaborator Kate Reed, former vice president for patient services at Children's Hospital Boston, who worked with the Amplatz clinical staff to identify issues and concerns. TK&A also partnered with Minneapolis-based Hammel, Green and Abrahamson (HGA), a national architectural and engineering firm that specializes in healthcare facility planning and design and had previous experience with Fairview Health Services.
During the planning and design phases, user groups were made up of experienced work teams with members from multiple disciplines. Involving the hospital's own physicians, nurses, and clinicians was critical for leveraging their “on the ground” experience of what works and what does not work, shedding light on concepts such as how to best standardize space, and then testing and signing off on those ideas through mock-ups. Jacobs Engineering served as the owner's representative for Amplatz, coordinating user groups and parent advisory groups. In addition, Amplatz's lead clinical researcher Lauren Johnson served as a coordinator for the hospital. With safety goals paramount, Amplatz also enlisted the expertise of John Reiling, MBA, MHA, PhD, of Safe by Design, a national specialist in safe hospital design, who facilitated a specific safety-oriented process with the team.
Together, the multidisciplinary team drew upon the continually expanding body of knowledge about improving safety, effectiveness, and efficiency in the healthcare environment. Each team member brought individual expertise and experience to bear on the project. Collaboratively, they applied the philosophies and principles of Lean, evidence-based, and safety-focused design and used mock-ups to incorporate features such as decentralized team stations; private, same-handed rooms; standardization whenever possible; visibility of patients; and daylighting to create a facility that enables and supports safety for patients and staff.
University of Minnesota Amplatz Children's Hospital
As the first step in a comprehensive and complex phasing strategy to upgrade its facilities, the University of Minnesota Amplatz Children's Hospital is adding a children's hospital on its Riverside campus, involving 353,100 square feet of new construction and 25,350 square feet of renovation. The six-story building brings a leading-edge pediatric care center to Minneapolis while supporting Amplatz's research and patient- and family-centered care objectives. The project includes 96 same-handed, single-occupancy inpatient rooms, a sedation/observation unit, a dialysis unit, a new pediatric emergency department, and an expansion of the existing imaging department and surgical suite, as well as a family resource center, a gift shop, and underground parking.
The plan calls for the creation of a distinctive identity for the children's hospital while also ensuring a coherent, unified campus where wayfinding makes navigation easy for patients, staff, and visitors. The massing and organization of the building reinforces the street edge and provides a prominent presence for the children's hospital along the main thoroughfare of Riverside Avenue. A one-story glass façade greets incoming visitors. Inside is a welcoming and centrally located information desk, a special events area for concerts, puppet shows, and other performances, and the family resource center, which features a special children's reading room.
The new building is organized by four neighborhoods of nursing units that are autonomous towers clustered at each corner. Interstitial areas that house the family lounge, playroom, and staff education room connect the towers. Natural light penetrates through these areas into the floor plate, illuminating the daily activities of patients, visitors, and staff. The transparency of the interstitial spaces on the south façade also promotes an urban connection between the hospital and the community, while the spaces on the east and west provide views and natural light.
Inpatient rooms, examination rooms, and procedure spaces are designed to accommodate and encourage family participation in a child's healing process. Diagnostic and testing services are located near their corresponding clinics and bed floors to improve the patient experience and increase staff efficiency.
An engaging and interactive interior design theme, called “Passport to Discovery,” celebrates the international and cultural diversity of the population served. Animals that have played a role in medical research serve as “storytellers” to enlighten patients and visitors about geography, ecosystems, sustainability, and milestones in scientific discovery.
Apply Lean to eliminate waste: Walk miles in their shoes
Lean production is a process that seeks to eliminate “waste,” that which does not provide value for the customer. In industry, types of waste include: overproduction, waiting, unnecessary transport, over-processing, excess inventory, unnecessary movement, defects and errors, and unused employee creativity. The core principles of Lean start with defining value: what does the customer want to gain from the process? In the healthcare environment, waste is anything that does not add direct value to the patient.
Involving its own internal Lean group and the design team specialists including HGA's industrial engineer Brent Peterson, Amplatz applied these industrial principles early on to the design of the healthcare environment in order to eliminate or minimize low-value tasks, operations, and elements.
At the core of Lean principles and the impact on safety is a recognition of the pressures facing staff in their day-to-day work. Reducing non-essential workload, distances, and time spent hunting and gathering supplies and medications reduces the stress and strain associated with those tasks. Eliminating waste allows hospital caregivers to focus on their essential work and avoid mistakes. Getting the right medications to the right patient in the right room and optimizing the time spent with patients contribute to a better and safer healthcare environment. In design terms, these concepts call for an approach that emphasizes decentralization and standardization.
The results of the nursing staff travel pattern study for Amplatz revealed evidence of waste in a proposed layout of new, larger inpatient units that had increased walking distances. Using “spaghetti diagrams,” the team observed nurses during a typical eight-hour shift, marking places and patterns of movement on the floor plan. The nurses walked a startling average of nine hours a shift-including time not spent providing direct value to patients.
The team then identified four key destinations: patient room, nursing desk, medication room, and nourishment center. Generating new unit layouts in a decentralized plan, the team created four nursing desks instead of one central desk, three medication rooms, and three nourishment centers-all convenient to patient rooms. Through design, nine miles a shift was reduced to five-saving four miles in time that could otherwise be spent providing direct value to patients.
The Lean process was applied to other concepts such as adjacencies and circulation patterns in the design of the facility. Another example of improvement and elimination of waste was the layout, flow, and sequencing in the medication rooms. Having supplies close at hand and minimizing distances to access points help to reduce medication errors.
Focus on safety-oriented planning and design: Avoid making the same mistakes
Under John Reiling, the team focused on process, culture, and facilities to assess design elements for their impact on safety (see sidebar #2). The team reviewed examples of active failures and assessed recent safety issues to better understand how facilities improvements could be made and to avoid repeating the same mistakes.
The team used a matrix process to analyze relevant safety data. “Learning labs” were hosted with multidisciplinary teams to discuss past issues and near misses, and to explore ideas for creating the safest possible healthcare and work environment. Failure Mode and Effects Analysis (FMEA), a tool that facilitates identification of potential problems in a design or process by examining the effects of lower-level failures, was incorporated at each stage of design, using several scenarios based on highest-frequency issues. Parents and family groups were involved in the planning process. Equipment planning and mock-ups were utilized. The team designed for the most vulnerable patient scenario and established a checklist for current and future design elements.
Draw upon evidence-based design: Safety is built in
Evidence-based design is used in the design process to apply knowledge and understanding gained from best practices and current research. The Amplatz team looked closely at a number of key design features, using evidence-based design to assess how they could contribute to creating a healing environment that not only is attractive and efficient but also as safe as possible.
Decentralized team stations. As supported by Lean principles, decentralized team stations, medication rooms, and nourishment centers bring care directly to the patient by reducing time spent out of the patient room and eliminating distances and distractions that impact safety. The decentralized plan at the new children's hospital provides visual supervision of each neighborhood and direct visual access to patient rooms and the hallway. The layout decreases congestion and noise, while supporting functionality and approachability. The presence of unit assistance at the entrance aids in directing families and visitors as well as controlling access to the unit.
Medication administration and supply. Creating dedicated medication areas for each care team station decreases the amount of time nurses spend running back and forth to a central nursing station. Outweighing the expenses and duplication of space and equipment, such as Pyxis and refrigerators, are the safety benefits of close access to each patient room. Some medications, such as first doses, nonrefrigerated, and non-narcotic medicines, are planned to be available in nurse servers. Automatic dispensing systems and electronic coding also contribute to reducing errors.
The use of nurse servers is based on the concept of getting specific supplies, materials, and medicines to specific patient rooms and in the specific quantities needed, thus minimizing opportunities for mistakes. An additional benefit is Radio Frequency Identification (RFID) coding and billing. However, the success of the system depends on supply factors and system efficiency to avoid overstocking medicines and supplies that cannot be used for other patients.
The Amplatz team addressed the debate on these issues, weighing in on locating nurse servers in all patient care rooms to decrease nursing “get” time and to decrease the number of staff who enter a patient's room. The servers are designed with a supply/care cart that is accessed in the room for care and slides back into the nurse server for stocking and storage from outside the room. Closets for storage of protective clothing and space for a future medicine drawer and personal protection equipment (PPE) also are provided. Servers are used on the bone marrow transplant floor to decrease critical time spent away from the patient. The server approach does come with a trade-off: the need to maintain air pressure and ensure that only one side is open at a time to ensure infection control.
Same-handed rooms. The jury is still out on the notion of same-handed rooms; however, there is compelling and evolving evidence to indicate that identical rooms encourage repetition and standardization that reduce the chance for errors and waste. The strategy makes intuitive sense. The overarching Lean concept of standardization suggests that in any situation, but especially in an emergency or code, caregivers can act immediately and respond in any room because everything is identically placed. Studies show that approaching a patient from the same side every time reduces the likelihood of error. Likewise, the identical arrangement of headwalls makes access to necessary services and equipment second nature and immediate.
Applying these evidence-based and human factors, the Amplatz team decided to develop right-handed/same-handed private patient rooms instead of mirrored rooms in the new facility. The team offset initial higher construction costs due to the fact that elements such as plumbing chases cannot be shared and, in fact, are doubled, by using off-site prefabrication of identical sets whenever possible.
On-stage/Off-stage concepts. A guiding principle for the Amplatz was the separation of circulation and flow of activities into the “on-stage” public environment and the “off stage” requirements of services. A central supply corridor with dedicated service elevators brings all supplies, clean and soiled goods, medications, and equipment to units, preventing clutter in the main corridors. The continual traffic of supply, housekeeping, and environmental activities is maintained out of view and without disturbance to patients and families.
Specific safety elements impacting design (latent conditions):
Noise reduction-on-stage and off-stage corridors;
Scalability, adaptability, flexibility, automation-decentralized team stations and decentralized medication rooms;
Visibility of patients to staff-decentralized team stations and windows on PICU;
Patients involved with their care-parent and family space integrated in the room;
Standardization-same-handed, right-handed rooms;
Minimize fatigue-decentralized care team stations, medication rooms, and nutrition centers, on unit staff lounge with natural light; and
Immediate accessibility of information, close to the point of service-decentralized care team stations, charting stations in room, PICU charting alcoves.
Sufficient and diverse collaborative space; Staff respite and support. The new Amplatz facility acknowledges the importance of work environment design on safety. Evidence-based design points to the critical need for appropriate respite spaces, including a variety of different kinds of spaces, such as quiet and active and outdoor and indoor.
Space is designed to support the caregivers. Care team stations and options offer both privacy and visibility. Units include sufficient conference space and flexible collaborative space, as well as interdisciplinary work areas. Adequate technology is provided at multiple locations to enable communication and monitoring. With ample collaborative meeting space, staff lounges are dedicated solely to staff respite and refreshment. Additional small staff respite rooms are located on the bone marrow transplant floor. Exterior areas and a staff garden encourage staff quiet time among the calming and refreshing effects of nature.
Integrated family space. The involvement and integration of parents and families in the treatment of children is central to Amplatz's mission and its delivery of healthcare. Rather than being viewed as an obstruction to care, parents are honored and recognized as active participants. Supporting parents as an integral part of the care team is one of the leading concepts in safety and evidence-based design. Having parents included in the care plan and present in the room as much as possible has been shown to improve the delivery of care. Parents who are educated about their child's care, ask questions, and participate with the care team contribute to safeguarding a child's best interests, comfort, and safety.
For all its benefits, incorporating families into care can be challenging in terms of providing family space in the pediatric intensive care units (PICUs) and addressing the need to have parents leave the room at necessary times. Infection control concerns in the bone marrow transplant area make it difficult to support family meals, and refrigerators in particular. As with other design options, Amplatz established a Parent Advisory Board to help test ideas and make decisions.
Through the efforts of Amplatz's Parent Advisory Board, specific items such as sleeping options were incorporated into the design to allow parents to sleep next to and hold hands with a child and to be visible upon the child's awakening. The hospital and design team also concentrated efforts at making the child's view from the bed as reassuring as possible, replacing clinical examination lighting with familiar lighting fixtures, providing entertaining distractions, and concealing medical equipment in the headwalls.
The children's hospital is designed with 90 net square feet of family space in each medical/surgical and bone marrow transplant patient room, and with dedicated family space in each PICU room. Included are sleeping options for two parents-one couch/twin-size bed and a layback glider in each room and a layback glider in the PICU. A round “kitchen” table encourages family meals, games, and schoolwork to provide a sense of normal family life and activities that contribute to healing. A computer desk gives families a place to work and an Internet connection, with donated computers for family use in each room. Microwaves and refrigerators in each medical/surgical room allow families to keep preferred foods on hand, and a family wardrobe and “hotel safe” accommodate family belongings.
In addition to family space in each patient room, the design includes ample opportunities for parents to leave the patient rooms in order to refresh, relax, or relieve stress. The Amplatz facility is designed with two large family lounges on each floor: one dedicated to quiet and reflection and one with a television for more social and conversational activities. Comfortable seating, artistic features, and access to windows and views are incorporated throughout the patient floor. Family lockers are located at the entrance of the bone marrow transplant floor. Family support spaces allow parents to be at the hospital as much as possible to contribute to the care and safety of the child. These spaces include laundry facilities, storage, additional showers and lockers, and exercise equipment located in the adjacent building. A well-lit garage beneath the building provides convenient and secure access to the building and protection from the elements.
Daylighting, ergonometrics, and additional design opportunities. Maximizing access to daylight in all areas improves patient, family, and staff well-being while providing a warm, pleasant, and uplifting atmosphere. Other examples of carefully assessed, evidence-based design that can result in safety improvements include raising work counter space heights to 38″ for standing work and lowering heights to 29″ for sitting work, reducing staff fatigue and stress. Ceiling-mounted patient lifts, installed in four rooms per unit, ensure safe patient handling and reduce the likelihood of caregivers injuring themselves lifting patients out of bed or onto stretchers, or assisting them to bathrooms. Public handwash stations that are observed by unit staff improve infection control. Hand sanitizer dispensers are located in the main building vestibule and at all clinical department entry doors. Within each patient floor, four handwashing stations with sinks are located along the main corridors. A handwashing station also is located near the door within each patient room.
Lessons learned: Safety is still a learning process
The Amplatz project emphasizes the importance of thorough programming and planning for safety from the start, and offers several lessons for other healthcare institutions embarking on their own building projects:
create a foundation for decision making by clearly articulating the vision and guiding principles;
begin planning early, and incorporate a safety-oriented process in the programming phase if possible;
form essential multidisciplinary representatives in the user groups to enhance collaboration and ownership of decisions;
develop baseline data and prioritize areas on which to focus;
build mock-ups of key areas and have staff sign off on their decisions; and
price multiple options and identify pros and cons to enable informed decision making during the design and value engineering process.
Following the completion and opening of the children's hospital in the spring of 2011, Amplatz plans to utilize opportunities for direct and specific quantitative feedback. The hospital has built in measures such as inpatient surveys, annual staff feedback mechanisms, and quality committees to address success and failure modes and conduct root cause analysis, a problem-solving methodology to identify and correct or eliminate causes of problems or events.
Designing for safety is still a learning process. Applying Lean principles along with evidence-based and safety-oriented design allows institutions to better address issues, avoid waste, and eliminate mistakes. Projects such as the Amplatz facility are helping to raise the bar and establish benchmarks for building better and safer healthcare facilities. HD
Russ Williams is Vice President of Facilities and Operations at the University of Minnesota Amplatz Children's Hospital
Richard L. Kobus, FAIA, FACHA, is Senior Principal with Tsoi/Kobus & Associates, Inc. For further information, visit
www.uofmchildrenshospital.org. Healthcare Design 2010 August;10(8):57-68