Healthcare Workplace: A Design Diagnostic of the Surgical ICU
Upali Nanda (PI), Seluga Sekanwagi, Adeleh Nejati, Sipra Pati, Steve Jacobsen, and Camilla Moretti
Midwest Healthcare System, State of Ohio
HKS Inc. and Midwest Healthcare System
WHAT WAS THE AIM
The study objective was to explore the relationship between facility design, human experience and organizational efficiency, to understand current state, and inform the design of future state in the design of the new medical tower.
WHY IS IT IMPORTANT
The SICU in the Midwest tower is a successful unit which meets most KPI targets such as infection rates and fall rates. However, the HCAHP scores and the Rate of Use of Restraints are on the lower side. Additionally staff voiced some concerns with the organization in the HR Survey. This study sought to determine how the facility design may play a role in current performance, and use this insight to enhance the performance in the new tower.
WHAT DID WE DO | HOW DID WE DO IT
The study method involves a triangulation method using online surveys , on-site observations and interviews, and off-site spatial analysis using parametric modeling tools. Reported data (archival/ surveys/ interviews), observed data (shadows/behavior maps) and spatial data (proximity and visibility analysis) are analyzed together to understand the patterns that emerge. We synthesize user data into a series of user personas to call out the goals and concerns of each stakeholder within the context of the site. A detailed timeline of the study is shown below.
WHAT DID WE FIND
Key findings of the study relate to unit design and patient room design, and are summarized as follows:
Communication is Happenstance: Care team coordination tends to “happen” in the corridors and nurse stations; the stations become communication hubs, and a source for noise. The off-stage area, originally designed for team collaboration is not used for this role.
Access trumps Visibility: Nurses leave doors open for patient monitoring and immediate access. Often blinds remain closed and the doors are kept open. This combined with the extensive use of the care coordination hubs increases noise levels and perception.
Off Stage is “Out of Sight..”: The off-stage area was designed for team huddles; however, the enclosed and opaque space obstructs unit visibility and is used as a hide-away space. Staff complains about the space, and refers to the units as two halves- divided by the off-stage center.
Documentation is excessive and inefficient: Despite spending a majority of their time in documentation on the computer (see activity analysis) nurses still tend to hand-write their personal notes on patients to share with other care providers. This puts into question the efficacy of the current electronic health record system.
Connectivity in the unit is limited: Currently the unit does not have any technological connectivity between the nurses (no pager/ phone etc). The Unit Clerk is a key human connector. Although it is likely that this creates a “tighter” unit with a stronger personal connection, it is also evident that the lack of technological connectivity can affect timely call responses.
Nurse Station is the Nucleus of the Workspace: All key work related interaction, as well as work that does not require patient interface happens at the nurse station. Nurses, physicians, and other care team members use the nurse station as touch down spaces, as well as documentation stations. The offstage is under-utilized adding pressure on the nurse station and also making it a noise generator for the unit.
More space needed on the bedside: The number of care team providers in a room can reach up to eight or more in admissions and emergency situations - adequate patient room real estate and point of use supplies are key. Nurses also spend two-thirds of their shift in the patient room and strategies that allow them to monitor patients outside the room must be explored.
What is next
The Design of an ICU should take into account the complexity of the care delivery team, the advanced equipment and information needs, and timely access to medications and supplies. For future design, key drivers emergent from the study are summarized below:
Patient Monitoring: Visual, Auditory, and Virtual: It is important to allow all three levels of connectivity, with auditory and virtual connectivity, arguably, trumping the visual.
Care Coordination Space has to provide for “touch down” spaces that encourage happenstance conversations and rapid documentation. Observation shows the nurse station as a team station.
Connectivity: (nurse-patient; peer-peer; care team; care team-support services) There must be connectivity between patients and care team members without the bottle neck of a single professional such as the UC.
Access to Medication must be conveniently situated, as well as secure. It should be possible for the nurses to prepare and administer meds without interruption, while being visible to the unit.
Security of the unit is paramount for the SICU which often deals with victims of potentially volatile situations (such as gang wars). Patients and staff must be secure, and “feel” secure as well.
Care Delivery Space in Patient Room: The ICU patient is connected to a lot
of large equipment and is treated by a large team (up to 8 or more people at the bedside)- often simultaneously. Space and power supply are essential at the bedside.