WHD_2012_Patient Unit Comparison Study

1. Retaining the Caring Presence and
Healing Touch in New Generation
Asian Hospitals: Learning from the
American Experiment
8TH DESIGN & HEALTH 2012 KUALA LUMPUR

2. Agenda
 Introduction – Decentralization
 Study Objectives
 Context – MD Anderson Cancer Center
 Data Collection
 Findings
 Summary

3. INTRODUCTION

4. Drivers and Design Impacts
 Single patient rooms
 Larger footprints
 Proximity challenges
 Decentralization
 Decentralization
 Use of technology
 Healing presence/time at the bedside
 Teamwork

5. Hypothesized Impacts
 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

6. OBJECTIVE

7. Objective
To examine the impact of decentralization on operational
efficiency and teamwork – drivers of the healing touch
and caring presence.

8. Goals of the Study for MD Anderson
 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

9. STUDY CONTEXT

10.  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

11. M.D. Anderson Cancer Center Growth
 1998 – 1999
20% growth in patients
 1999 – 2008
80% growth in patients
75% increase in
employees
 115% increase in
research revenue
 2012 Projections
50% growth in patients
from 2006

12. Then and Now

13. 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
THEN

14. Central Nursing
Station
Albert B. and Margaret M. Alkek Hospital
THEN

15. Unit Configuration
 Centralized work
concept
 Open medication
prep areas
 Family waiting areas
small/lacking
 Wayfinding
challenges
THEN

16. Key Design Goals and Objectives
The new Alkek patient units were 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
NOW

17. 1. Improved staff
circulation within
core
2. Decentralized
staff stations at
patient rooms
3. Decentralized
meds and
equipment
4. Created team
rooms
1 1
22
3
3
3
3 4
44
4
Design Solutions - Staff
N
NOW

18. 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
NOW

19. 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
NOW

20. DATA

21. 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

22. Data Collection 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

23. 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
 KU Scale

24. TCAB PDA

25. 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

26. FINDINGS

27. 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

28. Identifying Patterns of Change
Multiple unit
comparison benefit

29. Identifying Patterns of Change
 Performances change after intervention
 The key question is consistency

30. PDA Task Category: Documentation
15
17
19
21
23
25
27
29
31
33
Unit A Unit B Unit C
Before
After

31. PDA Task Location: Nurse Station
25
27
29
31
33
35
37
39
41
43
45
Unit A Unit B Unit C
Before
After

32. PDA Task Location: On The Unit
0
2
4
6
8
10
12
14
16
Unit A Unit B Unit C
Before
After

33. PDA Task Location: Medication
0
2
4
6
8
10
12
14
Unit A Unit B Unit C
Before
After

34. PDA Task Location: Supply Storage
0
0.5
1
1.5
2
2.5
Unit A Unit B Unit C
Before
After

35. Pedometer Walking Distance
1.5
2
2.5
3
3.5
4
Unit A Unit B Unit C
Before
After

36. Collaboration/ Teamwork
Question Direction Significance?
UNIT PRIMARY WORKSPACE
The amount of space in your primary
workspace fits your needs
UP 1 OF 3
You have sufficient work surfaces in your
primary workspace for your equipment and
work
UP 1 OF 3
You have enough storage space in your
primary workspace
UP 2 OF 3
You can change your workspace as needed
to fit your needs
UP 1 OF 3
PRIVACY IN PRIMARY WORKSPACE
You have enough privacy in your primary
workspace to do your job (e.g.,documentation,
charting, and/or dictation) well.
UP 0 OF 3

37. Collaboration/ Teamwork
Question Direction Significance?
PRIVACY IN OTHER SPACES
You feel that you are not interrupted by
others as you work in patient rooms
DOWN 0 OF 3
You feel that you are not interrupted by
others as you work in medication room/s
DOWN 0 OF 3
ENVIRONMENTAL FEATURES
Your primary workspace gets enough natural
light
DOWN 0 OF 3
Your primary workspace has sufficient
illumination for your needs
DOWN 0 OF 3
You are able to control the temperature in
your primary workspace when needed
DOWN 0 OF 3
You are able to control air
velocity/movement when needed
DOWN 1 OF 3

38. Collaboration/ Teamwork
Question Direction Significance?
UNIT WORK SUPPORT
When you need a computer, there is one
available
UP ALL
You can easily monitor your patients from
unit workspaces
DOWN 0 OF 3
The people you need to work with are
available in the unit when you need them
DOWN 2 OF 3
Overall, you are pleased with the design of
your unit in relation to your work
DOWN 0 OF 3

39. Collaboration/ Teamwork
Question Direction Significant?
COLLABORATION + TEAMWORK
Overall, the layout of your unit supports
teamwork or collaboration
DOWN ALL
Your unit has adequate space for formal
team meetings
UP ALL
Your unit has adequate space for informal
team meetings or interactions
UP 1 OF 3
Meeting spaces are generally available in
your unit
UP 1 OF 3
Patient rooms are large enough for
teamwork and collaboration
UP ALL
Corridors are wide enough for informal
interactions
UP 1 OF 3

40. Collaboration/ Teamwork
Question Direction Significance?
WALKING
You spend more time walking in your unit in
relation to other activities
UP 2 OF 3
Walking takes away from the time you would
otherwise have for patient care
UP ALL
Walking takes away from the time you would
otherwise have for collaborative work
UP 2 OF 3

41. Focus Group Interviews
The Nurses Speak…
 Increase in computerized documentation
 Medication room is now farther from many rooms. Lots
of walking
 Location of pneumatic tube station
 Finding “other staff” difficult
 Different processes for medication record use on each
unit

42. 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

43. SUMMARY

44.  Operational design must match physical design
intervention to achieve desired outcome
 Culture change is the most important challenge
 Unit size and shape appears to be key determining
factors affecting collaboration and teamwork

45. Healthcare
Pamela Redden, MD Anderson
Cancer Center
predden@mdanderson.org
Debajyoti Pati, Texas Tech
University
d.pati@ttu.edu