It’s become increasingly clear that the problem of patient safety doesn’t lie solely in the hands of clinicians or frontline staff. Healthcare systems have many underlying conditions that interact in complex ways and may result in adverse events, such as injuries, errors, and infections. These are known as “latent” conditions that contrast the visible “active” failure. These latent conditions (holes and weaknesses) often go undetected. And those that exist in the physical environment are often incorporated into facilities during planning, design, and construction. To that end, The Center for Health Design (CHD) is developing a proactive safety risk assessment (SRA) toolkit that will help healthcare design stakeholders think about these issues upfront.

This tool will support the requirement for a safety risk assessment that will be included in the 2014 edition of the Facility Guidelines Institute’s (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities. The resource, which will be part of a larger toolkit including whitepapers and educational modules, is funded by the Agency for Healthcare Research and Quality (AHRQ) and the FGI.

The framework
The first year of this three-year project was focused on identifying key design considerations for patient and worker safety in six focus areas: falls, healthcare-associated infections, medication safety, security, psychiatric injuries, and patient handling.

Based on a broad literature review of research, consensus documents, guidelines, and best practices, a range of design features and strategies were identified in the six hazard areas to consider early in the design process to best address patient and worker safety in healthcare environments. Through two rounds of an online survey, followed by a face-to-face meeting, six subject matter workgroups agreed to the set of considerations included in the tool. While there was not always 100 percent agreement, through rewording and modifications, each group came to a consensus—an acceptable resolution that could be supported by at least 70 percent of the group.

In the first round of consensus surveys, the experts indicated that healthcare design stakeholders (the project team) would likely search for information around safety-related design features based on the physical location of their project (inpatient unit, emergency department) or on potential hazards (falls, infections, etc.), as required by the Guidelines. For example, a project that involved the renovation of a medication room would need to conduct a SRA for medication safety, security, and infection but not psychiatric injury or patient handling, while a larger patient tower project might need consideration of all hazard areas.

To further discuss ideas for adoption and implementation, as well as any barriers or unintended consequences, the seminar participants were grouped into six project scenarios (new Greenfield facility, renovation of public spaces). However, each group’s discussions focused on common issues that were independent of the scenario presented, with many posing adoption and barrier questions. On the adoption side, debate largely surrounded financials and outcomes, training and education, support from leadership, and the need for a culture of safety. Barriers noted included availability of resources, tool burnout/“make work” perceptions, a lack of understanding of the relationship of design to safety, and fear. Lastly, the groups determined that use of the SRA was an opportunity for increased collaboration and coordination, but could slow the design process if not effectively embedded into the process.

In summary, the participants felt the proactive consideration of safety early in design would have a high impact but also take some extra effort.

Next steps
Currently in its second year, the project is now focused on developing the interface, testing, and validating the tool. The third year will be dedicated to educating healthcare design stakeholders. Key partnerships with national organizations such as the MedStar Institute for Innovation, Kaiser Permanente, FGI, American Society for Healthcare Engineering, and the National Institute for Occupational Safety and Health, and other national industry experts will ensure that the tool represents the needs of the healthcare design community.

It’s hoped that the end result will:

  • Be used during the early design process
  • Support understanding of the Guidelines
  • Strengthen the focus on patient and worker safety in the design process
  • Facilitate multidisciplinary engagement and communication around safety issues
  • Grow as the evidence base grows.

Look for updates to the continued development of the tool in the coming year in CHD webinars and other industry events.

Anjali Joseph, PhD, EDAC, is director of grants and research advisory services at The Center for Heath Design. She can be reached at Ellen Taylor, AIA, MBA, EDAC, is an architect and built environment researcher, serving as the director of research for The Center for Health Design in Concord, Calif. She can be reached at