The Top 3 Patient Safety Concepts Influencing Hospital Design

August 11, 2010

Hospital Building Teams are giving increasing attention to patient safety, and with good reason: The Institute of Medicine reports that as many as 1 out of 27 patients admitted into a hospital is harmed by preventable error, and that 1 out of 500 patients dies as a result of preventable error.

According to The Wall Street Journal, one hospital that set up a toll-free complaint line saw reports of medical errors or near-misses increase from 250 a month to 3,000 a month once an anonymous call-in number was established.

While many healthcare organizations are putting improved patient safety at the top of their list of concerns, Building Teams that specialize in the hospital sector face a dilemma: a lack of hard data to show what design concepts truly improve patient safety and the true costs and benefits of such investments.

BD+C interviewed leading architects and researchers to determine what patient safety designs they advocate and what issues they face when designing healthcare facilities. Their top three patient safety design concepts: 1) design for the caregiving process; 2) design for standardization; and 3) decentralize nursing stations—but proceed with caution.

1. Design for the caregiving processes. Because it is generally assumed that there is a direct correlation between staff performance and patient safety, it would make sense for hospital design to address medical and nursing staff practices and processes. But that’s not always the case, says Thomas Wallen, AIA, principal with Gresham Smith & Partners, Nashville.

Wallen and his team are responsible for the design of the $51 million, 80-bed St. Joseph’s Hospital in West Bend, Wis., which is considered the nation’s first hospital designed specifically to address error-free medical delivery.

“Many environments force work-arounds,” says Wallen, referring to the process of forcing nurses and doctors to find ways to work around—instead of with—the facility’s built environment to accomplish their tasks. That can be dangerous.

“Approximately 70% of hospitals’ preventable errors or potential errors are the result of process error,” says Wallen, referring to an in-house study of these issues by Gresham Smith. Design is often out of sync with staff processes because blanket statements are made about the best or safest ways to design hospitals, for everything from how and where medication is administered to the direction from which doctors approach a patient’s bed.

These “best practices” may run counter to the facility’s culture of care, says Wallen. “What works for one hospital doesn’t necessarily work for another. These are very complex decisions,” he says.

The simple solution, according to Greg Mare, AIA: “Talk with the staff about how they do their jobs in order to figure out how to design for them,” says Mare, SVP and director of planning for architecture firm Karlsberger, Columbus, Ohio. Each design element—no matter how popular it is, or how effective it is supposed to be, or its supposed benefit to patient safety—needs to be evaluated for the hospital environment; otherwise, it may have the potential to do more harm than good.

Mare and his team paid extensive consideration to the hospital’s user processes before designing the $150 million Dublin (Ohio) Methodist Hospital, which is set to open this November.

2. Design for the highest possible level of standardization. Standardization refers to much more than common room layout. It also refers to room size, type, and location. “Standardization means everything is identical, which has the effect of reducing error, reducing operating and initial costs, and improving efficiency,” says Wallen.

There’s an on-going debate in hospital design circles over same-hand room design versus mirror-reverse room design; that is, whether it’s safer to have the bed oriented against the same wall in each room (same-hand design) or to have beds oriented against opposite walls (mirror-reverse design).

Wallen argues that same-hand design makes patient rooms identical, so their use becomes intuitive to caregivers and therefore safer. His design for St. Joseph’s Hospital included not only identical bed orientation, but also identical locations for gas and oxygen outlets, medical equipment, and bathrooms, and even six identically stocked drawers of bandages, gauze, and cotton swabs in each room.

However, there is no conclusive evidence supporting one layout as safer than another. This uncertainty can deter hospitals from using same-hand rooms, especially when added costs are involved. Although costs vary, same-hand room designs can be more expensive because each room requires its own plumbing chase and oxygen and gas drops. Others would argue that same-hand room design reduces costs because of the repetitiveness of construction.

“When we’re promoting change, we need evidence showing it’s the right thing to do,” says Michael Czyrka, associate principal and managing director of the Chicago office of BSALifeStructures, headquartered in Indianapolis. “Healthcare is so dollar-driven these days that we have to prove that same-handed room design will not only improve patient safety but also save the hospital money,” he says. “The evidence to prove it isn’t there yet,” says Czyrka.

In fact, The Advisory Board Company, a Washington, D.C., think tank whose members include 2,500 of the country’s largest and most progressive health systems and medical centers, says there is no indication same-hand rooms are safer than mirror-reverse rooms and are therefore not a necessary investment. Their research indicates that same-hand rooms cost, on average, $3,500 more than mirror-reverse rooms.

The board’s recommendation: standardize the headwall, not the bed location, a design that increases constructions costs by only $300 per patient room.

That’s the course taken by Curtis Qualls, associate principal and senior healthcare planner at Jonathan Bailey Associates, Dallas, for the design of the new $111 million Winnie Palmer Hospital for Women and Children in Orlando, Fla. Every one of the 273 rooms uses mirror-reverse design. “My preference is that everything in a room have the same adjacency, that headwalls are standardized with medical gases [and oxygen] always being either to the right or the left of the bed. It doesn’t really matter which side the headboard is on,” says Qualls.

Michael Pukszta, a principal in Cannon Design’s St. Louis office, thinks he has the perfect solution: mix and match patient rooms. “Standardize same-hand rooms where the chances of a critical event happening are extremely high—and therefore the chance for error is high—such as in the emergency department or intensive care unit,” he says. “But use the more affordable mirror-reverse room design in acute-care patient rooms where the chance of a critical event occurring is much lower,” as is the total financial investment.

Another technique for improving safety and cutting construction costs is to reduce the number of standardized room types. “The average hospital has about 15 different room types. We narrowed it down to five,” says Marc Budaus, AIA, VP with Dallas-based design firm HKS.

For the $65 million, 530-bed Boca Raton (Fla.) Community Hospital, Budaus standardized the size of most patient rooms, NICUs, and exam rooms at about 335 sf, while LDR (labor, deliver, recovery) and operating rooms average 826 sf. This minimizes differences within the hospital environment and creates the standardization and repetition that can improve safety and efficiency.

3. Decentralize the nursing station—carefully. Our experts concur on decentralizing nursing stations, but they caution restraint when planning for decentralization because it’s easy to lose sight of how nurses really deliver care. “Be careful of getting rid of the central nursing area entirely because nurses like camaraderie,” says Nicholas Watkins, PhD, director of research for Cannon Design.

HKS’s Budaus agrees. “Providing care is a collective, team activity, and nurses are social people,” he says. “To say there has to still be a central nursing station may be overstating the issue, but there should be somewhere for nurses to meet and collaborate.”

At Boca Raton Community Hospital, Budaus decentralized the nursing stations by locating small teaming stations throughout the patient units, but he also still included a central nurse work room and conference space to accommodate collaborative care delivery. Gone is the traditional central nurse station with transaction counter overlooking the unit. Gone, too, is the central file storage: all medical records are going electronic.

Budaus’s blending of the best of the new (decentralized stations) with the old (central collaboration space) is indicative of how many experts are approaching hospital design. They see this kind of alchemy as a solution to greatly improved patient safety.

Decentralized nursing stations improve patient safety by putting the nurses in close proximity to the patients, which improves both observation and response time. They also cut down on distractions because they allow nurses to immediately start and complete their charting. They also cut down on fatigue by drastically reducing nurses’ travel distances—no longer does a nurse have to walk an average of five miles per shift.

The location and number of decentralized nursing stations vary according to hospital design, but some experts recommend one per room for same-hand patient rooms and one nursing station positioned between every two rooms for mirror-reverse patient rooms.

Curtis Qualls of Jonathan Bailey Associates designed the Winnie Palmer Hospital with one nurse station for every 12 rooms (three nurse stations per floor, on average) but the patient units are circular so nurses are only 18 feet away from any room and have a 360-degree view of the entire unit. “It’s about getting patients closer to the caregivers to improve safety and efficiency,” says Qualls

In his design for Dublin Methodist, Karlsberger’s Greg Mare created six nurse ”perches” within each of the hospital’s 20-bed units. “There’s one perch for roughly every three to four beds,” says Mare. “They don’t add square footage, they just redistribute it so costs weren’t even a factor.”

Two more ways to enhance patient safety
While the experts agreed that designing for process, standardization, and decentralized nursing stations are the top three patient safety concepts influencing hospital design, they volunteered two additional ideas worth considering.

1. Locate bathrooms on outside walls to improve sightlines into the bathroom.

Outboard bathrooms can be monitored by nurses from their nursing stations, from hallways, or from within the patient’s room itself. This enables nurses to monitor the bathroom more closely and observe potential problems when the bathroom door is closed for extended periods.

Note: Outboard bathrooms decrease the room’s window space and can eliminate some square footage from the room’s “family zone.”

Recommendation: Locate the bathroom door on the same wall as the headboard so that patients have a continuous handrail running from the bathroom to the bed to help prevent falls.

2. Eliminate hallway hazards.

Alan Sneed, AIA, project manager at RTKL in Dallas, doubled hallway widths from eight feet to 16 feet at the Center for Advanced Heart Care at the University of Kansas in Kansas City. The wider hallways have two tracks—one for staff use, one for patient use. Because patients recovering from heart surgery have to be mobile almost immediately, they need a hallway free of foot traffic, wheelchairs, and food carts to safely perform their walking exercises. The hospital’s cardiotrack occupies the hallway’s inside loop. Sneed lowered the ceiling and used softer lighting to visually separate the track from the rest of the hallway. Black flooring tiles every 10 feet helps patients track their distance.

Double hallways need not take space away from the hospital units or increase construction costs. “It’s about smart design, planning, and materials rather than adding things that cost more,” says Sneed.

Recommendation: Design to reduce the number of doorways opening into the cardiotrack (or any hallway) so the handrail has fewer interruptions, says Sneed.