Find design issues at the right time in the construction process that could affect patient and staff safety.
By Nora Colman, M.D., and Kiran Hebbar, M.D.
Hospitals and health care systems strive to construct facilities that provide safe and cost-effective care. The physical space where patient care takes place is strongly linked to patient and staff safety. This concept can be explained by the “Swiss cheese model.” When multiple holes or weakness in a system align, an “accident waiting to happen” is destined to occur.
In health care facility design, decisions made by architects, designers and planners during the design process, while inadvertent, may result in system weakness. These “holes” or weaknesses in the system are known as latent safety threats (LST). LSTs can create workflow and process inefficiencies, health care-related errors or poor job satisfaction for staff.
For example, the layout of a clinical space may result in excessive walking for staff that leads to fatigue. Improper placement of hand foam may affect hand hygiene compliance. Confusing signage may create a subpar patient and family experience. Additionally, processes that worked well in previous workspaces may not translate well into a clinical space that is physically larger.
What's more, these weaknesses are often recognized too late in the process and changes to design elements may be expensive to retrofit, or a patient experiences a health care-related error. The ability to identify weaknesses before the patient experiences them helps organizations mitigate risk. It also offers health care systems a chance to make improvements before an accident reaches a patient or causes harm to a staff member.
Safety threats identified
Awkward hand sanitizer location
Inconveniently mounted diagnostic sets
Evaluate a space for weakness
Using a different approach to design newly built health care facilities, Children's Healthcare of Atlanta applied simulation-based clinical systems testing (SbCST) to improve the safety of delivered care before opening a facility. In the summer of 2019, Children's Healthcare of Atlanta opened the Center for Advanced Pediatrics, a new, free-standing pediatric subspecialty outpatient center, estimated to serve more than 100,000 pediatric patient visits per year.
Hospital teams conducted simulations three months prior to opening the facility and evaluated 15 clinical areas. The scenarios represented unit workflows with the goal to improve patient safety and workflow efficiency.
This provided an opportunity to evaluate the space for holes or weaknesses. Simulations provided a clinical context so frontline staff could interact with their new space in a dynamic way. The process prompted teams to actively experience and interact with equipment and technology while performing the tasks necessary to deliver care. This shared experience helped teams to work through intricacies of care delivery as opposed to imagining it. As a result, weaknesses were more effectively identified.
During SbCST at the Center for Advanced Pediatrics, 150 clinical staff participated in simulations, and 150 leaders observed. Clinical staff included physicians, respiratory therapists, nurses and medical assistants who would be working in the new clinic. Additional participants included those from registration, patient and family experience, security, lab technicians and radiology technicians. Local emergency medical services also participated. Clinical, administrative, operational leaders and clinic educators observed simulations for each of their designated areas.
Simulated scenarios were designed for each clinical area to represent the patient population and their varying clinical needs and represented routine clinical care. For example, many of the teams simulated an entire patient visit. They worked through the intake process, attainment of vital signs, and the movement of the patient through the clinical space, from the waiting room into the exam room.
Physicians and consultants then performed their assessment. This prompted them to interact with the electronic medical record and in-room charting. During routine care, clinicians evaluated exam room furnishings and mounted medical equipment. Simulated clinical care also included lab draws and radiographic assessments.
The scenarios then concluded with discharging the patient from the clinic. These simulations highlighted how patients, staff and equipment would move through the space. Staff was able to experience what their workflows would look like, how they would communicate with other team members, and where they would access equipment and supplies when needed.
Teams also simulated emergency scenarios representing low-frequency but high-risk situations, such as a patient in the endocrinology clinic with diabetic ketoacidosis. In another scenario, a patient developed a seizure and respiratory distress in the neurology clinic.
Scenarios also evaluated how emergency medical services would navigate through the building to pick up a patient who needed to be taken to an emergency room. These scenarios were used to stress the environment and evaluate the process surrounding emergency preparedness.
Identifying safety threats
Simulations revealed more than 300 potential LSTs related to workflow, process and resource allocation. During simulations, staff identified the location of antibacterial hand sanitizer was not in an optimal position for hand hygiene compliance. Mounting of diagnostic sets, such as otoscopes and ophthalmoscopes, caused providers to reach awkwardly over the patient. There was inadequate seating for caregivers of technology-dependent children who came to clinic with bulky equipment and supplies.
Lack of consistency in provider use of electronic tracking boards highlighted the need for additional training. Confusing signage and wayfinding inside the clinic and the parking areas were discovered. Staff discussed ways to access storage areas, such as changing from a keypad to badge access.
These inefficiencies in process, workflow and resource allocation were affected by the built environment. In moving from a small space to a larger footprint, clinicians discovered workflows, processes and communication styles that worked well in their previous clinical space were not effective in the new building. Staff were used to having visibility with their colleagues if they stepped out of a clinical room or peeked their heads out of their workstations.
Due to the larger space and noise reduction technologies, teams realized modes of communication would have to be modified. As the teams interacted with their new environment, it was clear many assumptions were made about how care would be conducted in the new space. The work as it was imagined during planning, did not always translate to work as it was done during simulations.
Finding positive outcomes
Simulation provided an opportunity to modify process, relocate equipment, and better allocate resources before opening. It also highlighted the need for additional training as part of transition planning. For example, following SbCST, physicians were offered additional training on how to use a tracking system to communicate with teams more efficiently. Additional simulations for emergency response teams on efficiently responding to medical emergencies in the clinic was also identified as an opportunity.
This collaborative effort brought together teams of frontline staff members as part of the hospital's “dedication to better” mission. The most immediate and evident effect of simulation was the empowerment it gave providers. They felt like everyone was listening, and their voice was heard regarding facility planning. Involvement of nurses, physicians, respiratory therapists and medical assistants was an invaluable opportunity.
The feedback staff provided was essential to ensure the design met their needs and those of patients and families. The opportunity for staff to help shape the design of clinical areas fostered a sense of collaboration, enthusiasm, investment and ownership of the space.
SbCST provides an approach to building safer, more efficient and thoughtful health care facilities. Teams can apply this type of testing to any clinical space, whether it be a clinic, operative area or inpatient space. It can also be used to evaluate a newly renovated space, small facility or large-scale hospital project.
SbCST can further help to ignite the journey of change management, interfacing ideal workflow with organizational priorities. Most importantly, SbCST keeps patient safety and health care quality delivery at the forefront of planning and decision making.
Nora Colman, M.D., is a pediatric intensivist, and Kiran Hebbar, M.D., is a pediatric intensivist and medical director of the Simulation Center at Children's Healthcare of Atlanta. Send questions or comments.