Lessons learned from designing a heart hospital
In August 2002, one of the country's first all- digital, patient-centered, freestanding cardio-vascular care hospitals opened in Oklahoma City. Hailed as a new model for cardiology facility design, it quickly became an industry benchmark. Since opening, Oklahoma Heart Hospital reports that it is in the 99th percentile of the Press Ganey inpatient satisfaction database, placing it among the top one percent of the facilities with which it is being compared.
While Oklahoma Heart Hospital has proven to be successful for its owners during its first three years of operation, there are always lessons designers can learn in seeing how well the building facilitates the delivery of healthcare. A year after the hospital opened, the designers went back and met with Michael Schroyer, former president of Oklahoma Heart Hospital and now principal of TRG Cardiovascular, for a postoccupancy evaluation (POE). In addition, they talked with physicians, administrators, and staff to find out what works and what doesn't, and to see what lessons could be learned for future projects.
The result of a partnership between Oklahoma Cardiovascular Associates and Mercy Health Center, the 78-bed hospital was designed by Watkins Hamilton Ross Architects (WHR) of Houston. The design team worked with physicians and Mercy Hospital administrators to design a hospital with the heart patient in mind every step of the way. The owners' goal was to create a unity of care not found anywhere else. To do this, a “critical path” for patients was established to minimize their waiting times and transfers. Private patient rooms are equipped with specially designed beds to easily accommodate x-rays without moving the patient (figure 1). Ancillary service departments, such as respiratory therapy, pharmacy, and lab, are conveniently located on the patient-bed floor (figure 2).
Private patient room with bed specially designed to accommodate x-ray equipment
Plan of patient-bed floor
Another goal of the project was to accommodate the latest in digital technology. High-resolution digital monitors in patient rooms and throughout the hospital allow physicians and staff to instantly access any clinical information on patients, including all medical images, medication and allergy reaction records, past procedures, and consultations with other physicians. Secured through a privacy network, the system also allows physicians to log on from their homes.
The hospital's distinct shape and form (figure 3) communicate to patients and visitors that they are important. A dramatic four-story atrium lobby with natural light streaming in from the north window wall evokes a warm welcome for visitors. Balconies from the patient floor cascade out over the atrium, giving it a tremendous feeling of spaciousness. The ground floor concierge desk gives visitors a place for convenient check-in, information, and assistance. A natural color palette provides warmth, incorporating wood and stone into the design scheme.
To the west of the lobby are the preadmission testing area, family waiting, day patient suite, cath lab suite with five procedure rooms, and surgical suite with four procedure rooms. To the east are the A La Heart Café and dining room (figure 4), chapel, and other support services. The emergency department is located in the rear, with a dedicated patient and ambulance entrance. Inpatient beds occupy most of the second floor and part of the third floor. Oklahoma Cardiolovascular Associates' outpatient practice occupies approximately two-thirds of the third floor. The heart hospital is connected with the Mercy Hospital campus via a tunnel at the basement level.
Lessons Learned: Waiting, Preadmission
Many of the patients coming to the hospital are not from Oklahoma City, so they often bring along multiple family members. Patients may be supported by as many as ten or more family or friends who would normally be waiting together. Some feedback has indicated that the waiting room adjacent to the day patient suite (figure 5) should have been at least a third larger. However, based on physician feedback and facility tours conducted by WHR, the conclusion is that it is really about the right size and is perhaps at times underutilized.
Although most of the hospital's diagnostic imaging services are located on the second floor, making access convenient for inpatients, these services are predominantly used by outpatients. Locating imaging services on the ground floor, with discrete access for inpatients, would have created a more convenient experience for outpatients. The amount of preregistration activity that has occurred since the opening also suggests that the heart hospital would benefit from a larger preregistration area.
The placement of three consultation rooms between the family waiting area and cath lab suite has created positive feedback from both cardiologists and families. The central location allows family members to receive procedure updates without forcing them to venture very far into the hospital. Equally important, cardiologists and cardiovascular surgeons have to walk only a short way to consult with family members.
Lessons Learned: Cath Lab, Surgical Suites
Instead of cath lab rooms being located opposite one another and separated by the control area, they are situated in a row, with one common control area running behind each cath lab (figure 6). This layout not only allows the possibility of future expansion without compromising the efficiency of the linear layout, but it also provides the cardiologist with a connected area to socialize with colleagues and view other procedures. In addition, all four cath labs are identically designed, which eliminates disorientation from one procedure room to another. In each case, the cardiologist has visual contact with the cath lab technician, who is also able to view the patient. The cardiologist stands in front of the cath equipment, looks up to see the monitors, and looks right to see the technician who is monitoring the patient (figure 7). The size of the room and relationship of all the caregivers to the patient work well.
Exterior view, Oklahoma Heart Hospital
A La Heart Café and dining room
Waiting room adjacent to the day patient suite.
At the request of one of the hospital's thoracic surgeons, the four operating rooms in the surgical suite (figure 6) are also identically designed. In addition, depending on the positioning of the lighting, table, and equipment, each operating room can accommodate either a left- or right-handed surgeon. Although the additional medical gas and electrical outlets cost a little more, the convenience and flexibility for the surgeons make up for it.
The operating rooms are adjacent to an exterior wall, allowing for the possibility of borrowed daylight. Given the amount of time surgical teams spend in the OR, having natural light and a view outside is an amenity they really appreciate.
Within the surgical department is an oversize critical care elevator that provides quick and direct access to an eight-bed intensive care unit (ICU) directly above. Unlike the two hospital-size elevators in the middle of the hospital, the oversize ICU elevator accommodates a patient bed, transport staff, and medical equipment. Looking back, it would have been worthwhile if the elevators in the middle of the hospital had also been oversized. Many patients are admitted through the emergency department with critical coronary needs requiring quick moves to diagnostic imaging or to an inpatient bed unit, and they are often surrounded by a transport team and IV poles and other medical equipment. Traversing through surgery at level one to access the ICU elevator is not an option. Centrally located elevators with oversize cabs would have allowed easier vertical transport of these patients.
First-floor plan (note convenient layout of the cath lab and surgical suites)
Lessons Learned: Day Patient Suite, Emergency, Dining
It is always important to incorporate flexibility into a facility design, especially if it means potentially accommodating additional patients. Since opening, Oklahoma Heart Hospital has already experienced many near-capacity days. For this reason, the hospital might have benefited from a more flexible day patient suite that could satisfy health regulations for overnight stays. Then, when inpatient census increased on the bed floor, the day patient suite could have satisfied criteria to operate as an overflow nursing unit. In that case, each day patient room would have needed its own toilet room and an exterior window. Also, based on projected volume, this 15-bed unit should have been about five beds larger.
Throughout the programming and design work, it was understood that ambulances would bring all emergency patients to the main hospital across the street. Patients triaged and determined to have cardiovascular-related problems would then be transported to the heart hospital for special care. During early design work, administrators only wanted to create an efficient and minimally present emergency area that would satisfy state health codes. Halfway through construction, however, a new CEO was brought on board to guide the development of the heart hospital. Although the ER was designed to satisfy initial emergency management, midway during construction the new CEO suggested floor plan changes to potentially provide additional ER examination areas.
An efficient concept emerged that is still in place today: The adjacent Post-Anesthesia Care Unit (PACU) and ER share a common nurses' station and have a connecting corridor, allowing peak-time emergency visits to overflow within the PACU. Although, as mentioned, this generated a change order during construction, the efficient use of space and lack of redundancy in staffing has more than paid for the change. Ideally, five or six additional examination spaces, or perhaps a separate overflow area adjacent to the ER, would enhance this concept further.
The hospital was completed just prior to the release in 2002 of revised HIPAA regulations governing patient privacy and confidentiality. Having flexible examination space separated by curtains was probably not the best solution in light of this. Cubicles or individual rooms, rather than open bays, are preferable for addressing patient privacy.
The number of visitors, and therefore the demand for the dining and deli area, exceeds the space and number of seats provided during peak hours of operation. The dining area for a community-based heart hospital of this size should be approximately 25% larger. In fact, the amount of space devoted to the kitchen was oversized by about the same amount. To save some costs, the hospital used the expertise of its in-house dietary manager for input on kitchen size and layout. It turns out that inpatient and visitor food service demand could have been accommodated with less kitchen space. Kitchen space in a heart hospital of this size should be a little leaner.
The second floor includes 46 step-down beds, 16 intensive care beds, and the Imaging, Diagnostics, Lab, Pathology, and Pharmacy departments. The location of these departments allows convenient access to inpatient services and, therefore, promotes operational efficiency. A dedicated elevator (mentioned before) transports patients from the first floor operating room to the second floor, directly adjacent to the ICU. All beds are situated in eight-bed clusters or pods. In addition, the horseshoe configuration of each pod promotes interaction among patients, family members, and staff by making the caregiver more visible and readily available. In comparison with a traditional side-by-side, linear layout, this design increases the amount of time a caregiver can spend with each patient, in proportion to the number of steps saved between rooms and nurse assignment areas.
The positive feedback the hospital has received indicates that the pod design works well. While this configuration promotes a quiet ambience for patients and families, it also allows staff members to monitor needs of their patients efficiently. This pod design is thought to be a first of its kind in heart hospitals.
Lessons Learned: Nursing Units, ICU
The eight-bed pod in the Step-Down Nursing Unit was selected because the maximum 1:4 nurse-to-patient ratio provides the flexibility to offer more intimate care while allowing a team of nurses, technicians, and physicians' assistants to be assigned based upon patients' specific needs.
Although the patient rooms themselves work well, the bathrooms should have been slightly larger. Cardiology tends to manage a higher percentage of obese patients, and caregivers' ability to assist these patients is compromised by the tighter bathroom configurations.
The 16-bed Intensive Care Unit is dedicated primarily to postsurgical patients who require stabilization, observation, and other critical care attention after surgery. The ICU consists of two eight-bed pods, each allowing staff clear visibility into the patient room. Specially trained nurses provide intensive care to patients within these two pods and, as a patient's acuity level diminishes and room is needed for other intensive care bed demands, the patient is eventually moved to a step-down bed for intermediate care. The design team did question the number of ICU versus step-down beds, thinking that the cardiologists would prefer a higher percentage of intensive care beds. However, the cardiologists have found that the 16 ICU beds available work well with the volume of service they provide.
Recent time-motion studies suggest that cardiology programs can benefit from acuity-adaptable room designs. In fact, several heart programs are looking at and have already implemented a “universal” patient room concept. By design, this model of care allows patients to remain in one room for the duration of their stay, bringing appropriate staff and medical equipment as necessary to meet their changing acuity needs. The Oklahoma Heart Hospital physician and administrative team was not interested in an acuity-adaptable design.
Nevertheless, given the opportunity to redesign and build the hospital again, physicians with Oklahoma Cardiovascular Associates say they would not have done it differently. Medical Director John Harvey, MD, speaking on behalf of the owners of Oklahoma Heart Hospital, said, “We are very happy with the design and believe we made the right decision to provide two levels of care. Most hospital-based cardiology programs have several levels of care, typically requiring several patient moves. Nurses providing postsurgical care in the ICU require different skill sets than those of nurses caring for patients in a step-down unit.”
Research has shown that efficient, effective, thoughtful building design that promotes healing for both patients and staff helps to increase satisfaction, reduce medical errors, and improve financial performance. By all accounts, Oklahoma Heart Hospital is a success, and the lessons learned from its design can inform future projects and help improve the overall quality of healthcare. HD