Has It Really Been Two Years? A Pebble Project Reflects on Success
Inpatient room satisfaction peer ranking moved from the 19th percentile to the 94th percentile. Falls with injuries were reduced by 86%. Medication errors were reduced by 19%. These are just some of the exciting results Paoli Hospital has witnessed since opening its new Patient Pavilion just two years ago. The 275,000-square-foot addition includes a replaced emergency department (ED), operating rooms, surgery department, as well as an intensive care unit/progressive care unit and new private med-surg rooms. The pavilion nearly doubled the size of the hospital to 487,000 square feet.
Paoli’s engagement with the Pebble Project
There were several issues that needed to be addressed in the new design:
- The 23-year-old emergency department was overcrowded and outdated. It was designed to handle 18,000 patients, roughly 50% of the volume in 2008, resulting in diversions or long wait times;
- The intensive care unit was also small, outdated, and not family-friendly; and
- The patient rooms were semi-private (90%) and too small to accommodate the families and equipment of today’s healthcare environment.
Using research and experience from the other Pebble Partners was an integral part of the design process. As a result, the following features were included in the design:
- An ED triple the size of the old ED, including fast track, multiple triage rooms, acute treatment rooms with improved privacy, and comfortable family waiting with separate children’s room and vending areas;
- A surgical department four times the size of the old space, with 12 state-of-the-art operating rooms and shell space for two additional operating rooms;
- A new and expanded intensive care unit and progressive care unit with 30 beds;
- Ninety-four new private patient care rooms with bathrooms and showers located off of the headwall; larger windows for increased natural light, “same-sided” rooms to improve orientation; and warm, comfortable surroundings with space for family members’ overnight stays (see Figure 1 for the typical inpatient unit layout);
- Improved visibility of patients through decentralized nurse station design;
- Healing gardens, accessible by both staff and patients;
- Increased natural light for staff throughout patient care areas, with staff lounges on patient care units and separate educational rooms on each floor; and selected artwork.
Naturally, after the dust settled, Paoli Hospital wanted to determine whether the new pavilion performed as it had hoped. Anecdotally, administrators know that it has met expectations, as the facility is completely full and target patient projections for what was anticipated to be several years down the road have already been hit. Comments from patients also tell a success story:
- “Excellent environment—the windows with a view, the décor—everything helped me relax.”
- “The hospital provided a five-star experience.”
- “Wonderful hospital! Really enjoyed having a private room!”
- “I was very happy that my husband got to spend the whole time with me in the hospital.”
- “I had a great experience. If I had to do it again, I would not think twice to come back to Paoli Hospital.”
Using several metrics and methods, below are some of Paoli’s findings.
Design strategies to reduce falls included increased visibility of the patient by the staff through the room orientation and location of nurse work areas. Grab rails are between the bed and bathroom door, which is located on the headwall. The rate of patient falls per 1,000 patient days has been reduced by nearly 10% in the new pavilion. The rate of falls with injury has seen an even more dramatic reduction of 86% (see Figure 2).
While the overall decrease in falls is not statistically significant (0.374>0.05), the rate of falls with injury is a statistically significant reduction at the 0.05 level (0.000<0.05). The injury rates were analyzed as a percentage of the total number of falls.
Medication errors decreased by 19% after moving to the new pavilion (see Figure 2). Design strategies to reduce medication errors included location of medications to a box outside each patient room and a medication room with a closed door to minimize distractions during medication preparation. The data used for the analysis were the medication errors and number of medications dispensed from January to December 2008 (pre-pavilion) and January to December 2010 (post-pavilion).
The parameters of interest were the medication errors per 1,000 medications dispensed before and after opening. Based upon the data, the error rate decrease was significant at the 0.05 level (0.021<0.05)(a two-tailed z-test was conducted to determine if the percentage changed significantly from the before period to the after period).
Paoli Hospital has one of the lowest infection rates in the state of Pennsylvania. As a result, it was not expected that the rate of change would be immediately identifiable (see Figure 2). In conducting the analysis of infections per 1,000 patient days for the period from February 2008 to March 2009 (pre-pavilion) and from February 2010 to March 2011 (post-pavilion), there was not a significant change at the 0.05 level (0.411>0.05).
Patient satisfaction at Paoli Hospital has always been high, but the opening of the pavilion contributed to a rise in satisfaction in both the inpatient units and the ED, as shown in the overall assessment means. In addition, the mean scores for ED arrival, inpatient room, and inpatient family and visitor sections increased. These trends are shown in Figure 3.
However, when satisfaction scores are already high, it becomes more difficult to affect change. While the increase in mean scores reflects some change, the ranking against peer facilities for these sections als
o saw a dramatic rise for the evaluation period of October through December 2010: ED arrival went from the 85th percentile to the 97th percentile, inpatient room from the 19th percentile to the 94th percentile, and the inpatient visitors and family went from the 25th percentile to the 97th percentile (these percentile ranking have seen another moderate increase with the most recent quarterly data).
Another way to evaluate these changes is through the changes in “the top box scores,” those scores where patients provide the highest score offered—in this case, “very good.” Top box data was gathered from the Press Ganey surveys for the pre-pavilion period of October through December 2008 and the same period in 2010. Questions related to the built environment for both the inpatient units and emergency department were evaluated.
For the inpatient units, questions regarding room décor, accommodations for family and visitors, response time to calls, noise, and room temperature were analyzed. In all cases, an increase in the percentage of “very good” was observed from the pre-pavilion period to the post-pavilion period, with all but “response times to calls” significant at the 0.05 level (see Figure 4).
For the emergency department, analyzed questions regarded comfort of waiting, family and friends with you, and privacy. In all cases, an increase in the percentage of “very good” was observed from the pre-pavilion period to the post-pavilion period, with changes in “comfort of waiting” and “family and friends with you” significant at the 0.05 level (see Figure 4).
In addition, an analysis considered the “very good” score for the overall units, many of which were relocated to the new pavilion. One unit that did not move was used as the control. Prior to the move, the inpatient units reflected a dramatic difference in perceptions, ranging from a “very good” satisfaction level of 46% up to 67%. Following the move, all units that moved to the new pavilion, as well as the unit that did not move, experienced a statistically significant improvement in satisfaction scores.
This supports a common philosophy that “a rising tide raised all boats” and points to the challenges of confounding factors. However, satisfaction at the “very good” level for the one unit that was a direct relocation (as opposed to a merging and redistribution of units) increased by more than 10%. Statistically controlling for the increased satisfaction recorded in the control unit, this improvement was still significant (0.0001<0.05)
A staff survey was also developed and administered after the move. Numerous items about the environment were included in it, such as feelings about materials, temperature, and noise; and the ability of the layout to facilitate communication, provide privacy, and improve everyday work tasks also was questioned (see Figure 5). Dramatic statistically significant increases were seen in all categories, except access to staff break rooms, which, while lower, was not a statistically significant change.
It’s always possible to learn from what has been done and continue to make improvements, but Paoli Hospital’s leaders have been pleased with its results to date. One of the lessons learned was to ensure that staff training and orientation continues following the opening of a new structure. There are so many changes happening simultaneously, it is easy for staff to feel overwhelmed and forget what has recently been taught. Paoli’s administrators also found it important to reinforce the everyday actions around safety and service. A new building can enhance and support good work habits but, by itself, will not create a safer and better environment for care. HCD
Jan Nash, PhD, MSN, RN, is vice president of patient services at Main Line Health and Paoli Hospital, a nonprofit community hospital serving western Main Line suburbs of Philadelphia and Chester County, Pennsylvania. Ellen Taylor, AIA, MBA, EDAC, is a research associate and consultant to The Center for Health Design. Data analysis was provided by Joseph Szmerekovsky, PhD, associate professor, management, North Dakota State University. For more information on Paoli Hospital, visit www.mainlinehealth.org/paoli.