Dr Firman Abdullah SpOG /ObGyn ( Dokter Spesialis Kebidanan dan Kandungan ). OFFICE : ACHMAD MOCHTAR GENERAL HOSPITAL.BUKITTINGGI MILITARY HOSPITAL

Hospital building design boosts patient safety: safety-oriented construction planning process

HealthCare Benchmarks and Quality ImprovementDec, 2002

Key Points

* Learning lab leads to pro-construction design process and guiding principles.

* Safety improvements are designed into new hospital building.

* The way a building functions can affect changes in organizational culture.

Even before the first spade .was turned in the ground, the new St. Joseph's Hospital building in Westbend, WI, was far safer than its predecessor. This was by design--construction design, that is.

"Ever since the [Institute of Medicine] report in 1999, which contained very powerful data in terms of error rates, we have been talking about the whole issue of human error and patient safety," notes John Reiling, MBA, MHA, CEO at St. Joseph's, part of a small, regional health system. "One of our administrative staff said we should start thinking about how to increase safety through hospital design as well."

About a year ago, Reiling also had the opportunity to discuss the issue with national leaders in the area of patient safety, including representatives from the American Hospital Association; the Joint Commission on Accreditation of Healthcare Organizations; the American Medical Association; the Institute for Healthcare Improvement; and several nursing schools. This was made possible through a "learning lab" program funded by a grant from the University of Minnesota.

The bulk of the work took place even before the design process began, Reiling notes. "We developed two key themes," he says. "First, that facilities design can impact patient safety; the very nature of a facility can cause you to make errors. It can be something as simple as where to put a sink so people will be more likely to wash their hands."

The second theme revolved around learning about designing safety. "The people we spoke to were not aware of any institution that had done homework on this subject, so there was nowhere to go to find out about designing safety," Reiling notes. "However, we realized [what we learned] could be helpful to the industry."

The learning lab was held April 18-19, 2002. "We were really honored by the caliber of participants," Reiling says.

In addition to the aforementioned organizations, participants included key physicians, board members, nurses, management, frontline employees, and supervisors. "We also included health systems we compete with and collaborate with in the region," he notes. In addition, the architects and contractors, who by then had been retained, participated in observing the learning lab; and some actively participated in the discussions.

"We talked about safety relative to the process of design, and whether there was something we should do differently," Reiling says. "We also talked about precarious events, which are somewhat similar to sentinel events. We went through major errors; for example, with falls, we discussed how to use facility design to lower the fall rate."

Through this series of discussions and breakout sessions, a series of recommendations was created, described in a six-page brochure. "We came up with our guiding principles of design and a checklist for employees to use to see if they were hitting the mark," Reiling explains.

In a traditional hospital design process, Reiling explains, you go through what is called a roll-in program, which encompasses how many beds you need to fill, what your patient volume will be, and so on. "Then, you basically translate rooms into spaces, then department adjacencies, and then you design a detailed drawing of each space," he notes.

The St. Joseph process was impacted by the safety emphasis. "When we talked about the rooms we needed, and the size required for, say, nursing rooms or radiology, we asked ourselves if they should be the same size if safety was our goal. This led to some changes," Reiling notes.

One of the areas impacted was adjacencies. "We conducted a failure mode analysis around each design phase," Reiling reports. "We tried to figure out the impact of adjacencies on safety."

For example, a draft of the adjacencies was studied for its impact on the most vulnerable patients. "We went through the [emergency department and asked what would happen if we had to do a direct admit to the [intensive care unit]," Reiling observes. "We talked about what could go wrong. As result of those exercises, we did modify our adjacencies."

Reiling says that St. Joseph's change in design strategy has contributed to a cultural change at the hospital. "We wanted this to change the culture of the organization, to make it more centered on safety, and there's no question it did this," he asserts. "If you focus on patient safety in design, you will change the culture."

Once people become engaged in the issue, the elements of a patient-safe culture were reinforced, he explains. "Take reporting what your errors are--you need to know that because you want to design around it," Reiling says. "Then, we started dealing with blameless cultures."

Designing a hospital takes a lot of organizational energy, Reiling adds. "If throughout the process, you talk about safety all the time, that in itself makes it a high priority, and you start to change how you operate. If you really think about facilities, they are the mechanisms through which we create processes."


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