Increasing efficiency and reducing waste have become key components for many aspects of the modern hospital, be it reducing patient waiting times and increasing throughput, or simply finding more convenient ways of doing things.

Frank Zilm, DArch, FAIA, FACHA, President, Frank Zilm & Assoc., and members of Ellerbe Becket undertook a study in which they examined emergency department layouts in respect to the walking distance of hospital staff in an effort to eliminate unnecessary walking and, hence, waste.

Zilm spoke with HEALTHCARE DESIGN about the results. He and members of the Ellerbe Becket team will be presenting their findings at HEALTHCARE DESIGN.10 during the session "Emergency Department Operations or Layout—Which is the Trump Card in Improving Efficiency?" The session will be held on Sunday, Nov. 14, in Room 313.

HCD: Tell me a little bit about Frank Zilm & Assoc.

Frank Zilm, DArch, FAIA, FACHA: About 95% of our work is healthcare. It divides up between master planning and specific functional programming for departments—emergency departments, surgery, and ambulatory care would probably be the largest areas. We also do work in academic research and medical center planning.

HCD: What initially drew you to studying the layout of emergency departments vis-à-vis staff efficiency?

Zilm: We have been involved in emergency room planning and design for about 20 years, and over the last 10 years, there’s been some alternative design concepts spearheaded by a number of people—myself and also James Lennon at Lennon Associates near San Diego, as well as other firms. There are three major physical organizational models for emergency rooms out there and talking with the team at Ellerbe Becket, we were speculating as to whether we could identify any efficiencies that could be gained on staff by the physical design. Staff walking in particular seemed to be something that could be measured relatively directly.

So we designed a study that would look at three sample emergency rooms of each design type. We had nine emergency rooms that were all brand new so there wouldn’t be any compromise over the original intent of the design; all community hospitals, all the same relative volume of patients. Then we designed a simple study where we put pedometers on all of the staff members and we looked at how much they were walking and if we could correlate any difference between the walking and the design layout.

HCD: Could you describe the physical differences between the linear, pod, and ballroom emergency department designs?

Zilm: If you looked at emergency departments 20-30 years ago, they would pretty much all be designed around what we call a ballroom design. You try to get as many treatment stations wrapped around a central observation control desk. That worked well for smaller emergency departments, but as the emergency departments’ volume continued to grow, there becomes a point where that kind of design concept starts to get compromised in terms of the goal of visibility and the balance of space in the central core area versus the patient care areas.

There are two alternatives that have emerged in the interim. One is a pod design where you break the treatment spaces down into smaller clusters and have decentralized work zones within each of the clusters. The linear design has an inner core area and you wrap the exam rooms around the perimeter of that core and you have decentralized work zones.

That’s a quick overview of the three major design concepts in emergency room design. Each of them from a physical, operational point of view has tradeoffs. They each have pros and cons and most hospitals now look very carefully now at what will work best for them. We were hoping that we could find some insight to see if there was anything that we could identify at this point relative to the design in terms of removing waste in patient care—and obviously walking is one dimension of wasted time.

HCD: And presumably the studies found a “best” layout?

Zilm: We’re not trying to give away what we found before the presentation, but the hospital’s choice on how they organized themselves turned out to be the most significant factor in the amount of walking that took place. It was interesting in the pilot study—and again, we’ve only done nine and what we hope to do is enlarge the study to see, with a larger sample, if we would get any difference—we did see differences between the nine hospitals. The hospitals that were the most efficient had done some very careful planning relative to Lean operations and techniques and had applied those techniques to their design solution. I think the bottom line is that you have to be looking at both pieces to be successful. You have to be looking at operational goals and techniques, as well as the facility design implications. You can’t really look at one or the other.

HCD: Aside from looking at other facilities, are you also looking into including other factors besides walking distance?

Zilm: Yes. There are other variables that obviously complicate studies of this nature. If we’re looking at ways to eliminate waste, there are a number of processes that could be looked at.

In terms of trying to correlate to design, we think walking is the key variable and if we could reduce the amount of time the staff spends walking, it would be significant. There are also correlated issues of—worker satisfaction, feeling of providing quality care for the patients—that are a little bit more difficult to measure but there are some techniques from the inpatient side and other areas that may help us measure those.

HCD: Are you looking at expanding the study to other parts of the hospital outside of the emergency department?

Zilm: Not at this time. There are some studies on nursing units that are going on relative to walking that we’re aware of, and that’s another logical place to look at. It would be interesting to look at the comparison between an emergency room and a clinic environment in the amount of walking. It would appear that the amount of walking in the emergency room would be significantly higher than what we would expect to see in a clinic setting, and that would be interesting to know if that’s true and why. We haven’t really looked at surgery or other areas to see if that would be a logical expansion. We’ve got a lot of work to do on the ED side.

HCD: Are you looking to contribute to the body of evidence-based design knowledge?

Zilm: We are measuring real activity in real settings so trying to correlate that to performance would certainly meet my definition of evidence-based design. I’ve served on the research board of The Center for Health Design for about five years now. The Ellerbe Becket people have submitted a proposal to the research council.

I think we’ll present what we have at the meeting in Las Vegas, but by my judgment, I think we need to get a larger sample size and expand the scope a bit in terms of what we’re trying to measure. We found some problems in what we thought would be some simple, straight-forward methodology: you put pedometers on people and you read the results. It turns out, particularly at nighttime, different places use their nursing staff in different ways. So the nurses at nighttime might be restocking rooms in some hospitals and not in others, so we would be getting very strange measurements in terms of walking per patient seen at nighttime at some of the sites. We’ve got to make sure we have a good solid methodology that we can track things like that to avoid noise in our studies. If we could expand that study, we’d learn a lot about how to do this. We also found that at some of the sites, staff got very competitive and they would go out and do laps around the emergency room so they would win the walking contest which was obviously not our intent.

Right now—perhaps one of the intriguing things—I think we’re getting to the point that we’ve got a methodology and an approach that anyone could do. If an emergency room wanted to do this kind of a study and compare their results, it would be a very simple study and very easily implemented, and it would not require a research team to do it. We could take this methodology and we could expand it so that others could participate, I think that would be a significant accomplishment