Postoccupancy outcomes of evidence-based design
Architects can design the greatest spaces, from progressive buildings that accommodate the most modern technologies to healing gardens that offer a natural, soothing break. Regardless of the technology or natural beauty involved in a particular project, however, any innovative concept must marry good design with operational success.
Example: Lutheran Medical Center (ELMC) in Wheat Ridge, Colorado, teamed with H+L Architecture to redesign ELMC's Intensive Care Unit (ICU) and Cardiac Care Unit (CCU). The team looked at this project from a big-picture view. It was an opportunity not only to redesign the physical environment, but also to incorporate a different model of care and the patient-safety protocols, to really change the way care was being delivered. Understanding how the model of care affects a healthcare facility's design and successful patient outcomes was paramount to the success of the project.
As part of H+L's ongoing commitment to evidence-based research, the firm tracked and measured patient outcome statistics for the new ICU and CCU units at ELMC and compared them with the outcomes in the previous units. The research to date shows that the redesign, the change in model of care, and the change in patient-safety protocols at ELMC significantly contributed improved outcomes in terms of healthcare, patient safety, and decreased costs:
The incidence of infection for patients on ventilators with ventilator-associated pneumonia decreased from 8% to 0%.
The mortality rate for ICU patients on ventilators decreased from 16% to 6%.
Patients and their families raved about the improved experience, and overall patient satisfaction scores increased from 80% to 91% positive.
The staff thrived in its new environment, with 0% voluntary turnover in the first three months the unit was open. This represents a substantial savings, because replacing staff is costly.
Getting the Synergy Started
An essential first step to achieving these results was including clinical staff in the design team from the beginning of the design process. It was critical for the design team to work collaboratively with staff so that the human factors involved in delivering quality care would be discussed. Early in the process, H+L found that it would take a concerted effort and a synergy of parallel design initiatives—including new patient safety protocols and models of care—with the new aesthetic design, or staff could easily revert to their old ways even in a new environment. The parallel design initiatives included:
Transformation of the ICU/CCU. In conjunction with the physical construction and change modeling, ELMC's ICU and CCU joined a VHA, Inc.-sponsored quality initiative titled “Transformation of the ICU” (TICU) that has helped improve clinical outcomes. The TICU project has changed the manner in which ELMC's teams provide care. The two primary changes have been the implementation of “bundles” and collaborative care rounds. Bundles are defined as evidence-based order sets that each ICU and CCU patient receives. Current bundles include appropriate sedation and pain control, oral care, bed positioning, glucose management, sepsis prevention, and other measures.
Collaborative care rounds are performed daily by a multidisciplinary team with up to 12 members dedicated to assessing every critical patient to ensure every need is met. The typical team includes a critical care pulmonologist or cardiologist from the CCU, a nurse, a registered dietitian, a respiratory therapist, a speech therapist, an occupational and rehabilitation therapist, a case manager, an infection control specialist, and an ethics and pastoral care representative. The team's charge is to ensure evidence-based care is provided either through the use of bundles or separate orders. Adherence to the bundles and the collaborative rounds has helped decrease ventilator-acquired pneumonia and has decreased overall mortality.
Lighting was enhanced throughout Exempla Lutheran Medical Center, giving providers more light for examinations along with lower indirect light levels for patient and family comfort.
An inclusive and collaborative design process. The staff's input led the project design team toward solutions that could be implemented in the new and renovated units. Caregiver stations were decentralized and moved closer to rooms to encourage more bedside time for nurses, and room size was increased, allowing easier access to patients and additional room for families. The new rooms range from 265 to 315 square feet; the existing rooms were 150 to 180 square feet.
Aesthetic details such as rounded walls, decorative columns, a warm color palette, and raised ceilings added warmth and a calming feel.
Lighting was enhanced, giving providers more light for examinations along with lower indirect light levels for patient and family comfort. Changes included the installation of indirect 2′ × 4′ fixtures over the bed for general lighting so that light does not shine directly in the patient's eyes. Dimmable downlights were added around the room's perimeter in the family zone to allow family members to control lighting levels, and in the caregiver zone to allow staff to control light to care for the patient without disturbing patient or family. Wall sconces were added outside each patient room to provide low-level lighting at night for circulation. Indirect 2′ × 4′ fixtures were added in the corridor ceiling located away from patient room entrances; this indirect lighting keeps light from shinning directly into patients’ eyes when they are being transported through the corridors (figure 1).
Group discussion was held on the change in the dynamics of staff previously located in a central nurses’ station versus being more independent in a new decentralized caregiver station.
The theme for the redesigned spaces was a less institutional, more hotel-like design, making patients and families comfortable and relaxed. Aesthetic details such as rounded walls, decorative columns, a warm color palette, and raised ceilings added warmth and a calming feel (figure 2). Decentralized nursing stations and carpeted corridors dramatically reduced the noise level on the units.
Engaging the staff early in the process and building a good working relationship that was conducive to open communication and the flow of ideas led to positive results, as did asking staff how they conduct their workdays. It was key for the team to remember that the project wasn't only a new space, but a new home and a fresh way of doing things for the staff members, patients, and visitors.
“Move Therapy” support group for staff. Although the staff's ideas were integrated into the design, the completed project represented significant changes from the old model of care. At first, there was some internal resistance and dissention about these changes. The Critical Care and Cardiovascular Services director initiated a facilitated “Living and Working in the Intensive Care Unit,” or “Move Therapy” support-group sessions with the staff three months before the move, to help them prepare for and adapt to the new model of care and physical environment. These weekly meetings’ sole purpose was to help staff build relationships and use effective change-management strategies as they transitioned into their new area. Staff members were asked to come up with a list of what they wanted to accomplish in these meetings. They said they wanted to stay patient-focused, define roles, streamline patient flow, coordinate services, deal with the “turf” wars, and cross-train for other positions.
To accomplish the wishes of the group, the director arranged for a facilitator with experience in workforce development and change theory to work with the staff. The team's focus would be on team building, creating a respectful work environment, assessing workflow, defining roles, and providing patient-centered care. Tools included in the sessions were Elisabeth Kubler-Ross's Five Stages of Grief and Loss, change-mastery tools, and constructive feedback. Each meeting was structured so that the theory was addressed first, followed by problem resolutions specific to the unit. For example, group discussion was held on the change in the dynamics of staff previously located in a central nurses’ station, where they could interact and exchange ideas about patient care, as well as socialize, versus being more independent in a new decentralized caregiver station (figure 3) . This helped the staff anticipate and adjust to the changes at move in.
As a result of these changes in design, models of care, and patient-safety protocols, patient outcomes were improved and Exempla Lutheran Medical Center presented a safer and more patient- and family-friendly facility to its ICU and CCU patients. HD
Fred Buenning, AIA, is a Principal in the healthcare segment of H+L Architecture in Denver.
Mary Shepler, RN, BSN, MA, is Director of Critical Care and Cardiovascular Services at Exempla Lutheran Medical Center in Wheat Ridge, Colorado.