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HCD_2011_MD Anderson study

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HCD_2011_MD Anderson study

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HCD_2011_MD Anderson study

  1. 1. E74: Teaming Up Does unit decentralization impact teamwork and operational efficiencies? Pamela Redden, MS, BSN,RN, EDAC, Director, Clinical Facilities Development UT MD Anderson Cancer Center Janet Sisolak, Project Director UT MD Anderson Cancer Center Debajyoti Pati, PHD, FIIA, LEED AP. Executive Director, CADRE; Rockwell Endowment Professor, Texas Tech
  2. 2. Acknowledgments  HKS Architects - Study sponsor and institutional support  Center for Advanced Design Research & Evaluation (CADRE)  Texas Tech University - Institutional support
  3. 3. Learning Objectives  Understand the impact of decentralization on the way nurses spend their time (efficiency).  Understand the impact of decentralization on walking distance.  Understand the potential influence of decentralized operations on presenteeism and acute stress of care providers.  Understand the impact of decentralization on care providers’ teamwork and collaboration.
  4. 4. Agenda  Drivers of decentralization  Key questions  The evidentiary challenge  The MD Anderson project  Study data  Key findings
  5. 5. INTRODUCTION
  6. 6.  Bed utilization: • Male – Female • Smoker – Non Smoker • Infection  Build fewer beds  Increase flexibility Driver of Decentralization: Single Room
  7. 7. Key Area of Change # 1  Increase in floor area per patient: • Larger footprint for the same number of beds
  8. 8. Key Area of Change # 2  Support space optimization: • Race track configuration • Decentralization
  9. 9. Hypothesized Impact Areas  Patient focused - More time with patient  Improved efficiencies - Reduced non-productive time - Reduced walking distance  Collaboration, teamwork and mentoring?  Stress reduction? - Chaos, noise - Socialization  Productivity improvement
  10. 10. Agenda  Drivers of decentralization  Key questions  The evidentiary challenge  The MD Anderson project  Study data  Key findings
  11. 11. Key Questions  Does decentralization influence time spent in walking, queues, and hunting and gathering?  Does it reduce non-productive tasks?
  12. 12. Key Questions  Does decentralization influence staff interaction and collaboration?
  13. 13. Agenda  Drivers of decentralization  Key questions  The evidentiary challenge  The MD Anderson project  Study data  Key findings
  14. 14. The AECOM Study  Six units  Three hospitals  Measurements: - Functional space use - Patient visibility - Noise level - Nurse perception of work environment  Findings: - Time spent on telephone/ computer/ admin higher in centralized - Consultation/ interaction less frequent on decentralized Centralized vs. Decentralized Nursing Stations: Effects on Nurses’ Functional Use of Space and Work Environment (Terri Zborowsky, et al.)
  15. 15. The Taiwan Study  Two units  Two hospitals  Measured: - Staff interaction - Patient falls  Findings: - Less communication in decentralized model - Less patient fall events in decentralized model Impact of Architectural Design on Communication among Hospital Staff. (Chai Hui Wang)
  16. 16. The WHR Study  Four units  One hospital  Measured: - Patient satisfaction - Nurse satisfaction - Communication - Walking distance - Medical outcomes - Organizational outcomes  Findings: - Increase in patient satisfaction - No significant differences in any other parameters The Effects of Nursing Unit Spatial Layout on Nursing Team Communication Patterns, Quality of Care and Patient Safety (Franklin Becker et al)
  17. 17. Agenda  Drivers of decentralization  Key questions  The evidentiary challenge  The MD Anderson project  Study data  Key findings
  18. 18.  Location - the heart of the Texas Medical Center, Houston, TX M.D. Anderson Cancer Center Background
  19. 19. • Texas Medical Center (42 member institutions, 13 major hospitals with 66,000 employees) • A healthcare component of the University of Texas • Founded in 1941, M. D. Anderson has grown to over 18,000 faculty and staff. • More than $2.2 billion annual revenue M.D. Anderson Cancer Center Background
  20. 20. • 1998 – 1999 20% growth in patients • 1999 – 2008 80% growth in patients 75% increase in employee 115% increase in research revenue • 2012 Projections 50% growth in patients from 2006 M.D. Anderson Cancer Center Growth
  21. 21. Then and Now
  22. 22. THE BEFORE CONTEXT
  23. 23. Typical Nursing Floor (4) 13-bed Units All Private Rooms Central Nurse Station Racetrack Design Service & Public Elev. Albert B. and Margaret M. Alkek Hospital
  24. 24. Central Nursing Station Documentation Station Albert B. and Margaret M. Alkek Hospital
  25. 25. Albert B. and Margaret M. Alkek Hospital Typical Amenities include: • Murphy bed for family members • TV/ Lodgenet • Storage for luggage, clothing
  26. 26. Unit Configuration  Centralized work concept  Open medication prep areas  Family waiting areas small/lacking  Wayfinding challenges
  27. 27. THE AFTER CONTEXT
  28. 28. Expansion Project – Initiated in 2005  503,000 Square Feet Added  11 Additional Floors - 8 Inpatient Units - Pharmacy - Facilities support - Mechanical / Electrical  Observation Deck  Current Operating Beds = 702  Future Operating Beds = 962
  29. 29. 1.Need to maximize the number and size of patient rooms per floor using current industry and best practice standards 2.Need to improve wayfinding for families and visitors 3.Need to add family spaces & amenities on floor 2 2 11 3 NN Design Challenges – Patient/Family
  30. 30. 1.Need to increase access to nursing stations 2.Need to improve staff and patient circulation 3.Need to improve support and staff areas 1 1 22 3 3 NN Design Challenges – Staff
  31. 31. Key Goals and Objectives The new Alkek patient units will be designed reviewing current evidence-based concepts in a manner that:  Promotes patient and family centered care  Maximizes efficiency of work effort for all members of the care team  Includes ergonomic considerations that minimize the physical burden of patient care delivery  Promotes interdisciplinary collaboration
  32. 32. Key Goals and Objectives Additionally, key design elements should be considered in relation to these guiding principles:  Promote safety for patients  Enhance support for patients and their families, recognizing that the family plays an active role in the healing process  Meet/exceed the needs of the care givers - integrate technology, maximize staff productivity, increase time at the patient bedside, minimize footsteps, enhance ergonomics
  33. 33. Design  Design-Build project McCarthy/HKS  Nursing Leadership Design Team 2006  Surveys on design topics- staff, physicians, caregivers, patients  Focus Groups - Medical Team Members - Staff - Patients & Family Members  Bulletins & Postings  SharePoint Site
  34. 34. Design Solutions - Patients/family 1.Increased footprint to accommodate more rooms per floor 2.Improved wayfinding on unit 3.More family waiting 4.Added consult room 1 11 1 33 22 44 NN
  35. 35. 1.Improved staff circulation within core 2.Decentralized staff stations at patient rooms 3.Decentralized meds and equipment 3.Created team rooms 1 1 22 3 3 3 3 4 44 4 Design Solutions - Staff N
  36. 36. Inpatient Floors 15–17: Typical patient room  Increased room size (ranges from 251 s.f.–298 s.f.)  Outboard toilet improves visibility of patient  ADA-sized toilet enhances accessibility  Improved family space  Easier access to patient  Caregiver work area within patient room  PPE alcove outside room
  37. 37. Inpatient Rooms Room Zones • Family Zone - Sleep Sofa - Additional Storage for Family - Individual Television • Patient Zone - Flexible Acuity - Desk Work Area - Headwall Ergonomics • Staff Zone - Hand washing sink inside room - Locked medication storage - C5 mobile computer
  38. 38. Decentralized Nurse/Staff Stations • Decentralized nurse/staff stations with patient view window • Improved view of patients for assessment purposes • Encourages staff time with patients • Decreases staff travel time • Distributed supplies/linen • Creates quieter environment Storage rooms and alcoves • Maintain hallways free of equipment • Support service areas (Lab, Nutrition) TEAM MEDS SUPPL Y Unit Staff Support Areas
  39. 39. Unit Staff Support Areas Medication Rooms • Locked medication rooms added to each pod on the new units • Addresses Joint Commission standards for medication security • Permits focused, uninterrupted medication preparation by the nursing staff Team Station • Fully outfitted admin area for Roving Patient Service Coordinator/Staff utilization • Central Physiologic Monitoring
  40. 40. Team Room Team Rooms • Multi-purpose rooms located on each pod to foster interdisciplinary collaboration and teamwork • MediaScape Smart Media Collaboration Table from Steelcase – data network connections w/ ability to display images from on-board desktop computers or laptops. • Web conferencing capable • Educational Initiatives • Glass walls of Team Rooms can be reconfigured if future utilization changes
  41. 41. STAFF AMENITIES – INPATIENT UNITS • Staff Tranquility/Working Mother’s Room • Locker Room ~ Staff Shower • Staff Lounge • Shared Multi-disciplinary Desks • Conference Room Staff Amenities
  42. 42. CLINICAL OPERATIONS
  43. 43. Unit Model STAFFING  Staffing typically 2-3 patients/RN  Support staff: CNAs and PSCs  Clinical Nurse Leader, AD, ANMs PATIENTS  Leukemia  Lymphoma  Stem Cell Transplant  “Mixed” hematology
  44. 44. Goals of the QI Project  Assist in adaptation to the new unit design  Identify new processes for Communication Collaboration Task completion Larger unit footprint  Seek opportunities Education and training Modify design elements
  45. 45. Study Protocol  14 staff data points for day shift/14 data points for night shift (per unit)  RNs carried PDAs and completed corresponding pedometer logs  PDA vibrates 30 times/12 hours, tasks and location entered  Filled out surveys
  46. 46. Study Protocol
  47. 47. Pre Occupancy Data Collection “Pre” Data Collection  January 18 – 31, 2011 G11 (Stem Cell Transplant) Alkek Hospital P6 (Hematology) Lutheran Pavilion  February 1 – 7, 2011 G9 East (Lymphoma Service) Alkek Hospital  Written Surveys for 2 weeks – January 15 – 31.
  48. 48. Activation and Occupancy  “Bed shortage”/high census impacts  Phased occupancy November 8, 2010 G16 G10W 26 beds to G16 48 beds March 7, 2011 G17E: 12 beds open March 14, 2011 G17W: 12 beds open May 16, 2011 G15: G9E to G15
  49. 49. Post Occupancy Data Collection “Post” Data Collection  September 8 – 22, 2011 G11 & G17 SW  September 26 – October 9, 2011 G15 & G17 SE  Written Surveys for 2 weeks – September 1 – 15
  50. 50. Activation and Occupancy Activation Management Team Operations Planning Move Management Communications Training Facility Readiness •Programs/Service s •Policies •Systems/Procedu res •HR Functions •Process Design •Operating Budget •Scheduling/ Sequencing •Packing/ Labeling •Department Relocation Management •On-Going Staff/ Employee Communication •Opening Events •Patient Communication •General Facility Communications •Operation Simulations •Training & Orientation •Master Training Schedule •Facility Planning/ Development/ Construction •Furniture/ Equipment/ Signage •Facility Completion/ Startup
  51. 51. Activation and Occupancy
  52. 52. Activation and Occupancy Training and Education Orientation methods First new floor challenges New workflow New team members
  53. 53. Educational Resources
  54. 54. Educational Resources • Short computer-based training modules developed to assist with training utilizing Camtasia PowerPoint Voice Over Program • Vocera • Bedside supply cabinets • Biohazard and linen pass-thru cabinets • Team Rooms • Multidisciplinary workrooms • Medical team rounds • Unit orientation • Medication room
  55. 55. Operational Factors  Children’s Cancer Hospital Expansion needed temporary inpatient unit.  Issues with showers and smoke dampers requiring moves of patients floor to floor before full occupancy.  Increase in monitored beds- decrease in ICU census
  56. 56. Operational Factors  Operating a 24 bed “unit” vs. 13 bed “pod”  Physician and medical team “centralized practice” concept  Staff rotations  Unit culture/staff roles
  57. 57. Post Occupancy Reviews  Staff feedback sessions August, 2011  Themes: o “Unit Spread Out”, harder to find people/staff o Patient assignments now need to consider geography o “View windows” yes or no? o Pod vs. Unit function o Like new medication room/system o Team room use by medical staff o Push button locks vs. badge
  58. 58. Agenda  Drivers of decentralization  Key questions  The evidentiary challenge  The MD Anderson project  Study data  Key findings
  59. 59. DATA TYPES
  60. 60. Data Types  Nursing time: - Rapid Modeling PDA  Walking distance: - Pedometer  Acute stress: - Current Mood State Questionnaire  Presenteeism: - Koopman Stanford Presenteeism Scale (Modified)  Staff interaction and collaboration
  61. 61. PDA TCAB Data Classification  Task Type - Value adding - Non value adding - Necessary  Task Category - Direct care - Indirect care - Administrative - Personal - Waste - Documentation - Other  Task Location - Nurse station - Patient room - On the unit - Patient medication - Supply storage - Conference room - Off unit - Documentation server - Other
  62. 62. Data Collection J F M A M J J A S O BEFORE DATA AFTER DATA UNIT A UNIT B UNIT C UNIT A UNIT A NEW UNIT B NEW UNIT C NEW 2011
  63. 63. Agenda  Drivers of decentralization  Key questions  The evidentiary challenge  The MD Anderson project  Study data  Key findings
  64. 64. Identifying Patterns of Change Multiple unit comparison benefit
  65. 65. Identifying Patterns of Change Care processes, physical environment, culture and policies interact PATIENT PATIENT OUTCOMES PHYSICAL ENVIRONMENT CAREGIVER CARE PROCESSES GROUP PHENOMENA: CULTURE RELATIONSHIPS POLICIES
  66. 66. Identifying Patterns of Change  Performances change after intervention  The key question is consistency
  67. 67. Task Category: Documentation 15 17 19 21 23 25 27 29 31 33 Unit A Unit B Unit C Before After
  68. 68. Task Location: Nurse Station 25 27 29 31 33 35 37 39 41 43 45 Unit A Unit B Unit C Before After
  69. 69. Task Location: On The Unit 0 2 4 6 8 10 12 14 16 Unit A Unit B Unit C Before After
  70. 70. Task Location: Medication 0 2 4 6 8 10 12 14 Unit A Unit B Unit C Before After
  71. 71. Task Location: Supply Storage 0 0.5 1 1.5 2 2.5 Unit A Unit B Unit C Before After
  72. 72. Walking Distance 1.5 2 2.5 3 3.5 4 Unit A Unit B Unit C Before After
  73. 73. Documentation 15 17 19 21 23 25 27 29 31 33 Before After After New
  74. 74. Nurse Station 30 31 32 33 34 35 36 37 38 39 Before After After New
  75. 75. On The Unit 5 5.5 6 6.5 7 7.5 Before After After New
  76. 76. Medication 0 2 4 6 8 10 12 14 Before After After New
  77. 77. Supplies 0 0.5 1 1.5 2 2.5 Before After After New
  78. 78. Walking Distance 1.5 2 2.5 3 3.5 4 Before After After New
  79. 79. IMPLICATIONS
  80. 80. Implications  Documentation increase  Is it because documentation stations/servers are more accessible in a decentralized configuration?
  81. 81. Implications  Nurse station use decrease  Is it because the need for documenting inside a nurse station is reduced?
  82. 82. Implications  On unit location increase  Associated with nurse station use decrease?  Does this represent an increase in inter- personnel collaboration/ interaction.
  83. 83. Implications  Medication room location increase  Because of easier access?
  84. 84.  Supply storage location decrease  Are supplies being delivered inside patient rooms?
  85. 85. Implications  Walking distance increase?  Counter intuitive  Does this represent an increase in inter- personnel collaboration/ interaction.
  86. 86. SUMMARY
  87. 87. Lessons Learned Operational planning vs reality - Paper intensive processes - Added Telemetry reduced ICU census - Geographic patient assignments new reality - Chemo and blood products require two-nurse checks - Feelings of isolation - Missed ‘teachable moments’ for new staff - Infection control discussions - Medications “at the bedside” on the wish list - Cannot get all supplies to the bedside

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