Research and Theory

The design of a new medical/surgical unit can cause mixed emotions among users of the space: excitement from knowing that an improved work environment typically equates to improved workflow but also anxiety regarding changes to staff processes and delivery of care. A classic example of this can be found in transitioning from a centralized to a decentralized model.

The existing body of knowledge on decentralized models is littered with research studies demonstrating improved working conditions, such as reduced travel distances and more time spent in patient rooms. However, it’s also acknowledged that users may experience a disconnection with colleagues due to an increased physical distance from one another and find that supplies often aren’t restocked appropriately.

Similar implications were experienced during the build-out project of an academic med/surg unit at Froedtert Hospital and the Medical College of Wisconsin in Milwaukee. Staff were used to working in a traditional environment and were skeptical that an update could make a difference. However, the project team used research, along with John Kotter’s eight-step change management theory, to aid the staff in adapting to changes in care delivery and the physical space. The unit was transformed from being centralized, where a majority of the supplies, medications, and charting/team stations were located at the elbow of the L-shaped unit, to decentralized, where these areas are now located at the bedside or right outside the patient room.

Kotter, the Konosuke Matsushita Professor of Leadership Emeritus at the Harvard Business School, introduced change management theory in 1996. His research found that organizations make eight common mistakes resulting in change failure. He transitioned these mistakes into eight steps that are needed for organizational transformation. The first three support a climate that promotes change by gathering buy-in from staff, creating a comprehensive project team, and working toward a shared vision. Steps four through six address the need for communication, information sharing, and supporting the team to think creatively by removing barriers. The final two steps make sure change is continuously improved and implemented. For this project, if frontline staff were resistant to change, desired outcomes established by the project team and organization wouldn’t have been met—no matter how the unit was designed. So, ultimately, change management was used alongside design research to help staff become more willing to accept and adapt to planned shifts in their processes and surrounding environment.

Three individuals from the HGA design team spent a week on the unit gathering qualitative data through patient and staff interviews and quantitative data through direct shadowing of staff. Just the presence of the designers asking questions and recording time-and-motion data was paramount in receiving buy-in from staff. It demonstrated to them that the design would be meaningful and data-driven, not just aesthetically pleasing.

At the first project meetings, documented findings were shared with staff that highlighted opportunities for improvement. Staff realized that if they worked in an improved environment of care delivery, their ability to provide better patient care would be strengthened.

For this project, the voices that were most impactful were those of the frontline staff. A project team was assembled that engaged staff to influence design decisions. Members included nurses, nursing assistants, nursing leaders, physicians, residents, therapists, supply chain workers, nutrition experts, and more. As the project progressed, staff were divided into teams that represented different user types and asked to engage in a variety of exercises. These exercises included space adjacency diagramming, where teams were able to organize the space according to their needs; “speed dating,” where teams asked one another questions about their processes; and information gathering, where teams were assigned to investigate specific topics of interest. All of these exercises aided in developing ownership from staff on future physical and operational changes.

For example, during an adjacency diagramming exercise, staff indicated that what they wanted closest to the bedside were supplies, linens, equipment, and charting stations. As a result, staff realized they were actually asking for a more decentralized environment to improve inefficiencies around their current workflow.

All the data collected during the early phases of design was used to inform the development of a design criterion called “critical to quality,” or CtQ, a Lean term in which critical needs (either operational or physical) are identified and addressed to support a quality clinical outcome (such as patient satisfaction or reduced patient fall rates). For this project, five quality categories were identified based on project-specific, data-driven needs. Operational and clinical outcome metrics were matched to each CtQ to measure and assess baseline and future-state performance. Image 3 provides the CtQs, matched evidence-based needs, and measures used to evaluate them.

Moving from a centralized to a decentralized environment was difficult for staff to envision. There was skepticism that their voices wouldn’t be heard, which led to angst that the new environment wouldn’t meet their needs. To address these concerns, not a single project meeting was held unless at least one clinical nurse was present. In the beginning, a few nurses served as primary participants, but toward the end of the project more than 50 percent of the unit’s nurses had participated in at least one meeting. It’s important to note that the staff most resistant to change were also invited to the project meetings, enabling them to express their concerns as needed.

As the design progressed, three different room layouts were mocked up to full scale, each with a different square footage to accommodate various patient room counts on the unit, confined to 19,400 square feet, including a 32-, 28-, and 24-bed unit. Staff simulated a series of common activities in each room to determine which best fit patient and staff needs. After each room simulation, staff assessed the rooms’ performance according to the list of CtQs. Pros and cons were outlined and reviewed, and a consensus was made to move forward with a larger patient room at 326 square feet and to decrease the unit size to a 24-bed unit.

Senior hospital executives were present during the mock-up simulations. Working through the simulation activity was paramount in receiving their buy-in, mostly because the total bed count was going to be reduced by eight beds. The staff felt reassured that their needs were being heard, with the presence of the executives.

Throughout the design process, data was shared with staff to demonstrate predicted improvement in workflow processes. For example, to receive consensus from staff on moving from a centralized to a decentralized layout, overlays of current-state data were used in spaghetti dia
grams of the future-state prototypes, demonstrating where significant improvements in workflow would be realized. Also, predictions were made based on post-occupancy results from prior benchmark studies of decentralized environments (e.g., a 5 to 10 percent increase in time spent in patient rooms). As construction progressed, staff frequently toured the construction site and were able to offer critiques that further refined the overall design.

In the midst of the design process, all frontline staff were asked to participate in a daylong event where staff worked out changes in operations and flow. This activity empowered staff to ask questions and suggest alternative solutions. A majority of the time, management was in support of the suggestions and worked to implement them.

Staff expressed a sense of loss when first caring for patients on the new unit. The decentralized layout was uncomfortable and isolating at first. During this time, leadership presence was extremely important for staff morale. Staff were encouraged to provide continued feedback, which aided in transitioning their frustration into flexibility and acceptance of the new model of care. To support a decentralized environment and to further reduce non-value-added activities, staff advocated for the following workflow changes post-occupancy:

A three-phase post-occupancy evaluation was initiated at Froedtert Hospital and the Medical College of Wisconsin that involved the same methodology used during pre-design. Direct shadowing of staff occurred at three, eight, and 12 months post-move. After each phase, a report of findings was provided to management. Although best practice is to wait until six months post-move to collect data, the phased approach provided insight and evidence around opportunities for further operational improvement. For example, three-month results showed nurses traveling to multiple supply locations, particularly in the afternoon when the stock for high-demand supplies diminished. This evidence was used to demonstrate to the supply chain that current par levels were insufficient. Furthermore, staff were able to work with the supply chain to create a more suitable par list. At 12 months post-move, trips to the servers drastically decrease from 86 to 49 visits per day shift.

This project demonstrates how research and change management activities work together to receive buy-in from staff on adjustments to operations and the physical environment. As a result, significant improvement was found in key CtQ measures, such as a 35 percent reduction in patient falls and significant improvement in patient satisfaction scores around space for visitors to participate in care (up 25 percent), quietness (up 15 percent), overall care (up 7 percent), and likelihood to recommend (up 4.5 percent). Also found was a significant increase in staff time spent in patient rooms (up 6 percent), along with a significant reduction in staff time spent traveling (down 6 percent).