Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
by
Eileen Malone Julie R. Mann-Dooks Joseph Strauss
for
HFPA Planning & Programming Division & TRICARE Management Activity PPMD
TABLE OF CONTENTS
EXECUTIVE SUMMARY ..................................................................................................................... 5 I. INTRODUCTION ............................................................................................................................ 9
II. A BRIEF HISTORY AND OVERVIEW OF EBD ...................................................................... 11 OUR DEFINITION OF EVIDENCE-BASED DESIGN .............................................................................11 THE THEORETICAL LINEAGE OF EVIDENCE-BASED DESIGN ..........................................................11 THE EVOLUTION OF EVIDENCE-BASED DESIGN .............................................................................14
EBD Research, Advocates and Researchers A Timeline...................................................................14 EBD Resources ....................................................................................................................................17 EBD Practitioners: Health Care Facilities..........................................................................................18 EBD in the Military Health System......................................................................................................19
III. CURRENT COMPELLING EBD SCIENCE .............................................................................. 23 EBD PRINCIPLE 1: CREATE A PATIENT- & FAMILY-CENTERED ENVIRONMENT ............................26 EBD PRINCIPLE 2: IMPROVE THE QUALITY AND SAFETY OF HEALTHCARE ...................................34 EBD PRINCIPLE 3: ENHANCE CARE OF THE WHOLE PERSON (CONTACT WITH NATURE & POSITIVE DISTRACTIONS).................................................................................43 EBD PRINCIPLE 4: CREATE A POSITIVE WORK ENVIRONMENT .....................................................45 EBD PRINCIPLE 5: DESIGN FOR MAXIMUM STANDARDIZATION, FUTURE FLEXIBILITY AND GROWTH ...........................................................................................................52 IV. EBD ACTIVITY CHECK LISTS ................................................................................................. 57 FACILITY LIFE CYCLE MANAGEMENT AND PERFORMANCE MODEL ..............................................57
Strategic and Business Planning..........................................................................................................58 Business Planning................................................................................................................................59 Facility Master Planning .....................................................................................................................60 Transition Planning .............................................................................................................................61 Project Planning ..................................................................................................................................61 Programming .......................................................................................................................................62 Design ..................................................................................................................................................63 Construction.........................................................................................................................................63 Commissioning and Occupancy...........................................................................................................64 Sustainment..........................................................................................................................................64
ATTACHMENTS.................................................................................................................................. 71 CASE STUDIES: FACILITY TOURS ....................................................................................................73 CASE STUDY: NCA/BRAC MILCON - APPLYING EBD PRINCIPLES ............................................75
EBD Design Principles used in Epidaurus ..........................................................................................75 Single-Bed Inpatient Rooms.................................................................................................................75 Patient and Staff Support on Inpatient Units .......................................................................................75 Other Patient-Centered Concepts Adopted..........................................................................................76
MEMO FROM DR. WINKENWERDER ................................................................................................77 FUTURE STUDY OPPORTUNITIES .....................................................................................................79 END NOTES ...........................................................................................................................85
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Executive Summary
Executive Summary
Introduction Over the past 10 years, Evidence-Based Design (EBD) has emerged as a scientific response to the questions about how the built environment impacts patient, staff and resource outcomes. EBD inquiry has exponentially exploded in the wake of the Institute of Medicines benchmark studies about the quality and safety of healthcare delivery in America. Military Health System (MHS) leaders want to understand the emerging science implications with regard to the Department of Defense health care facility planning, design and construction guidelines and then to provide an educational platform for their community. The Army Health Facility Planning Agency, funded by the TRICARE Management Activity Portfolio Planning and Management Directorate, contracted with Noblis (formerly Mitretek Systems) to conduct a research study as the basis for educating military healthcare planners. This report documents the results of this study, which includes an extensive EBD literature review (organized around the Department of Defenses EBD principles and goals), recommended EBD features and responses, and future study opportunities. In addition, EBD activities were identified for each phase of the Facility Life Cycle Management and Performance Model as a framework to facilitate the integration of EBD science across the continuum of medical construction projects and healthcare facility maintenance activities. Definition EBD represents an emerging body of science that links elements of the built environment with patient, staff and resource outcomes. The goal is to create a healing environment one that is safe, comfortable, and that supports the patient, the patients family, and the staff. Successful EBD depends on transformational leadership and culture and, frequently, a reengineering of clinical and business processes. While this synergistic response sometimes makes it difficult to completely ascertain the impact of the built environment alone in improving outcomes, there is strong and growing evidence that the application of EBD principles and features has a positive impact on patient, staff and resource outcomes. Overview & History EBD has evolved from the disciplines of evidence-based medicine and evidence-based practice. More healthcare evidence is collected every year, as the concept of quality in healthcare has come to the forefront of the American consciousness. Multiple groups have been formed to study EBD and augment the literature with new research and conclusions. The Center for Health Design is the largest advocacy group, and provides an excellent website with a compilation of resources on the state of the science. Professional design standards, such as the AIA Guidelines and the DoD Space Planning Criteria, have begun to reflect advances in EBD research.
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Executive Summary
The MHS has several concurrent ongoing studies that are relevant to EBD and has applied many EBD concepts in the programming, planning and now design of the Base Realignment and Closure Act (2006, BRAC)-generated facilities in the National Capital Area: the New Walter Reed National Military Medical Center at Bethesda and the New Community Hospital at Fort Belvoir. EBD Study The MHS has embraced five EBD principles, with attendant goals and desired outcomes as listed below. These principles served to focus the EBD literature review for this Study. 1. Create a Patient- and Family-Centered Environment reflecting the MHS culture of caring. Increase social support. Reduce spatial disorientation. Improve patient privacy and confidentiality. Provide adequate and appropriate light exposure. Support optimal patient nutrition. Improve patient sleep and rest. Decrease exposure to harmful chemicals. 2. Improve the Quality and Safety of Healthcare Reduce hospital-acquired infections via airborne, contact and water transmissions. Reduce medication errors. Prevent patient falls. Reduce noise stress and improve speech intelligibility. 3. Enhance Care of the Whole Person by Providing Contact with Nature and Positive Distractions Decrease patient and family stress. 4. Create a Positive Work Environment Decrease back pain and work-related injuries. Reduce staff fatigue. Increase team effectiveness. Eliminate noisy and chaotic environments. 5. Design for Maximum Standardization, Future Flexibility and Growth Reduce room transfers. Facilitate care coordination and patient service. EBD features and responses as well as future study opportunities were recommended. These findings were then translated into EBD activities across the facility life cycle. Recommendations An extensive literature review has identified compelling evidence that certain EBD features and responses do in fact improve patient, staff and resource outcomes. Although almost all of the EBD research was conducted in inpatient areas, some of these features suggest application in the ambulatory care environment. Though dependent on the project concept of operations and budget, this Study supports adoption of the following
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Executive Summary
EBD features in the program and design of virtually all new military health facilities. These features are supported by both compelling science and business case analysis. Design Single-bed Rooms with Family Zones to increase social support, improve patient privacy and confidentiality, improve patient sleep and rest, reduce hospitalacquired infections, decrease patient and family stress and eliminate noisy and chaotic environments. Provide HEPA Filtration to reduce airborne-transmitted hospital-acquired infections. Install Ceiling-Mounted Patient Lifts to reduce patient falls and decrease back pain and work-related injuries for staff. Use Sound-Absorbing Materials, Especially High-Performance SoundAbsorbing Ceiling Tiles to improve privacy and confidentiality, improve patient sleep and rest, reduce noise stress and improve speech intelligibility, and eliminate noisy and chaotic environments. Design Walled Rooms for Admitting, Examination and Treatment Spaces rather than open-plan rooms with curtains that divide separate patient spacesto improve patient privacy and confidentiality, provide adequate and appropriate light exposure, improve patient sleep and rest, reduce noise stress and improve speech intelligibility, decrease patient and family stress, and eliminate noisy and chaotic environments. Maximize Natural Light throughout the Building to improve patient rest and sleep, decrease patient and family stress, and reduce staff fatigue. Reduce or Eliminate Loud Noises to improve patient sleep and rest, reduce noise stress and improve speech intelligibility, and eliminate noisy and chaotic environments. Many EBD features represent good design choices and facility management practices. These often do not require significant additional front-end investments. Some additional EBD features with good supporting evidence include: - Residential-feelingrather than institutionalwaiting areas - Use of acuity-adaptable rooms for a combined intensive and intermediate care unit - Patient controls for light, glare and temperature - Improved lighting levels in medication preparation, dispensary and procedure areas - Windows in staff break rooms - Convenient food facilities for patients and families - Decentralized inpatient nursing support - Regular maintenance, cleaning and inspection of water systems - Proper water treatment practices - Avoidance of decorative water fountains in high-risk patient care areas - Frequent cleaning of high-contact surfaces - Providing sinks and hand-washing dispensers - Ensuring that HVAC systems are well maintained and operated - Use of materials and furnishings that do not emit toxins - Isolation of construction and renovation areas from patient-care areas - Providing secure access to nature - Providing positive distractions (music, appropriate art, etc.) - Providing multiple spiritual spaces and haven areas
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Executive Summary
Use of softer floor materials like carpet and rubber as appropriate Ergonomic evaluation of work areas Decentralized staff support spaces (e.g., supplies and charting areas) Providing flexible spaces for interactive team work Optimizing unit adjacencies with Care Centers (e.g., Cancer, Musculoskeletal Care)
Facility Life Cycle Management and Performance (FLCMP) Model Application EBD activities were identified for every phase of the FLCMP model from strategic planning to facility sustainmentnot just design, as is often thought. An EBD activity checklist for each FLCMP phase is provided in Section IV of this report. Recommended Next Steps. Much work is needed to institutionalize EBD research and findings, including the following recommended activities: - Engage senior leaders. - Partner with clinical and administrative peers. - Include patients and their families in health facility planning activities. - Review and update facility policy to include EBD-recommended features and responses. - Develop processes to harvest emerging EBD findings. - Review and restructure health facility organizations as appropriate to monitor and integrate EBD findings. - Conduct EBD research in the ambulatory and dental environments. - Disseminate EBD information. - Evaluate and refine EBD cost-estimating guidance. - Perform return on investment analyses. - Review EBD-associated outcome metric definitions and methodology. - Become a Pebble Project. - Refine the post-occupancy evaluation process. - Refine the life-cycle cost analysis process. - Publish MHS EBD experiences and lessons-learned. - Formalize current EBD working groups. Conclusion With a six-billion-dollar portfolio of new healthcare facilities and projects planned over the next five years, the MHS finds itself with a once-in-a-lifetime opportunity to both transform the healthcare infrastructure to improve patient, staff and resource outcomes and to contribute to the body of EBD science. This report provides a snapshot of the current EBD evidence applied to MHS EBD goals and principles that can be used to transform and educate the MHS healthcare community. Although the current AIA and DoD planning criteria embrace many of the recommended EBD features, the reader is encouraged to stay abreast of the latest EBD information through the Center for Health Design and is reminded that maximizing EBD investments depends on transformational leadership and clinical and business process reengineering. Employing recommended EBD features and responses across the Facility Life Cycle provides a singular opportunity to create the next generation of MHS healthcare facilities that can support the outcomes our warriors and their families deserve.
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I.
Introduction
The premise of evidence-based design (EBD) is that elements of a healthcare facility design have been scientifically evaluated and shown to make a positive difference in patient, staff, and resource outcomes. Some of the outcomes improved by EBD features include: improved patient and staff satisfaction, reduced hospital-acquired infections, improved patient sleep, and numerous others that will be discussed in this report. The Program and Planning Division (PPD) of the Health Facility Planning Agency of the US Army (HFPA), funded by the TRICARE Management Activity Portfolio Planning and Management Directorate (TMA PPMD), contracted Noblis, Inc. (formerly known as Mitretek Systems, Inc.) to complete research on Evidence-Based Design as a part of a Special Studies task orderi. The intent of this study is primarily educational, with a charge to educate HFPA and TMA planners about what EBD is, to examine the evidence, to understand how environment-friendly design fits in, and to determine how EBD might be applied in the military health system (MHS). Scope of Work Requirements There is a dizzying array of information available on the topic of EBD, and many groups within the MHS are addressing the issue. Noblis has attempted to interface with these disparate groups to align each groups separate objectives and to ensure that no one is duplicating efforts. This scope of work is focused primarily on educating the HFPA and TMA facility community stakeholders. The scope required that Noblis would: Perform a review of existing literature. Talk to those who have incorporated EBD principles and features in their designs. Identify resources that might be examples of best practices. Deliver a written final report documenting the issues, findings, implications and recommendations related to EBD for future military medical construction projects. Conduct an education session for HFPA planners. An educational presentation (entitled EBD: A Primer) was presented to the Team Army audience on March 7, 2007. An expanded set of presentations was given to an audience of 70 stakeholders on June 8, 2007. These morning presentations set the stage for an interior design visioning session for the new Community Hospital at Fort Belvoir later that afternoon. This report has been through a formal staffing process to elicit feedback from the facilities planning and programming communities. Their comments have been incorporated into this final draft. With the final publication of this report, Noblis has completed all of the scope requirements for this task.
Contract number W91278-05-D-0039, Task Order 0014; period of performance is OCT06 through SEP07.
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Methodology The Noblis team has conducted extensive literature review, attended numerous educational meetings and conferences, applied EBD principles to the facility life cycle as it is understood in the military health system, and investigated ways of incorporating EBD principles into the MHS. To educate the team members, Noblis (with HFPA and TMA) representatives attended: Turner Healthcares October 11, 2006 Executive Program: "The Business Case for Better Buildings" presented by the Center for Health Design, and The Digital, Integrated Healthcare Enterprise" presented by Siemens One. The Center for Health Designs Health Care Design 06 conference, November 4-7, 2006, in Chicago, IL. The Institute for Healthcare Improvements 18th National Forum on Quality Improvement in Healthcare, December 10-13, 2006, in Orlando, FL. The ASHE/AIA (American Society for Healthcare Engineering; part of the American Hospital Association and American Institute of Architects) 2007 International Conference and Exhibition on Health Facility Planning, Design and Construction, February 25-28, 2007, in San Antonio, TX. In the course of these sessions, members of the team spoke to many practitioners and students of EBD. The team gleaned much from their recommendations and referrals. Additionally, in the course of two conferences, the team had opportunities to tour regional health facilities that have adopted EBD principles in their new construction projects. (See Attachment 1 for details.) The Noblis team is also involved in the Epidaurus Project in the National Capital Area in the designs of Walter Reed National Military Medical Center and the New Community Hospital at Fort Belvoir. There has been a great deal of cross-pollination between Epidaurus and this study, as you will see in Section III of this report. This project is transforming the way the MHS looks at design of healthcare facilities. (For further information on this case study, see Attachment 2). Team The COTR project coordinator for HFPA is Ms. Miffy Morgan, Healthcare Planner. Additional oversight and direction is provided by LTC Mia Brennan, HFPA PPD, and by Mr. Clay Boenecke at TMA. The Noblis team consists of Eileen Malone, principal researcher and author; Julie Mann-Dooks, assistant researcher and author; Joe Strauss, architect and contributing author; and Doug Wilson, engagement director. Additional assistance was provided by Jeffrey Michaels, Noblis librarian, and Judi Potter, who helped to find multiple source articles and research studies. Overview of Report This report is divided into 5 major sections (preceded by an Executive Summary), which are detailed below.
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I. Introduction. Includes background for the study, scope of work requirements, methodology, and a description of the team. II. A Brief EBD History and Overview. A definition, brief history and overview of the science of EBD to include who the thought leaders have been and what institutions have adopted EBD features and responses. III. Current Compelling EBD Science. An overview of the compelling EBD scienceorganized according to the MHS EBD principles and goalswith a description of the literature review, recommended EBD features and suggested future studies. IV. EBD Activity Checklists. EBD activity checklists are provided for each phase of the Facility Life Cycle Management and Performance Model. V. Summary Recommendations, Conclusion and Next Steps. A summary of recommendations, conclusions and recommended next steps. Additionally, there are four attachments which give further information about case studies, provide the full text of Dr. Winkenwerders recent memo, and list the opportunities for future study that are identified in Section III.
II.
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treatments and interventions is available in the form of relevant randomized controlled trials. He strongly advocated that this evidence should be collected, analyzed, validated and then widely disseminated. Evidence-based medicine strives to use research-based knowledge to apply the best interventions to the clinical encounter. Evidence-based Medicine has led to Evidencebased Practice, in which clinicians, nurses and others apply research results to their subspecialty clinical practices. This same kind of scientific rigor can be applied to design elements. Kirk Hamilton (in his 2003 article "The Four Levels of Evidence-Based Design Practice) tells us that: Evidence-based healthcare designs are used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance, and restorative for workers under stress.5 He goes on to say that designers and clients must collaborate to sift through the available research and the project evaluations that have been completed, and use critical thinking skills to develop appropriate solutions to each clients unique design or healthcare delivery problems. EBD is neither a recipe nor a cookie-cutter approach; a lot of latitude is maintained for the design teams creativity and innovation. Usually, an evidence-based healthcare design will result in demonstrated improvements in the organizations clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures. But, as Hamilton warns, the EBD label should be applied only to projects in which current research has impacted the design and the hypothesized outcomes can be sufficiently measured1 those projects that are truly evidence-based. For eons, good healthcare facility design has incorporated positive healing features. In Ancient Epidaurus, 6th century BC, patient rooms in the temple to Asklepious were oriented to the sun, based on a belief that the power of the sun was healing. We now have scientific proof that morning sunlight does in fact help heal. Evidence-Based Design attempts to make empiric what was once intuitive.
Healing Environment
EvidenceBased Design Re-engineered Clinical & Administrative Processes
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As depicted in the model above, EBD cannot occur in a vacuum; it must be accompanied by both process re-engineering and cultural change. This message is strongly reiterated by those who have applied EBD features to their building projects. Leadership must make a commitment to the principles behind creation of a healing environment and ensure that these principles are incorporated into their entire organizational culture, from the clinicians to the nurses to the housekeeping staff to the administrators. Without cultural and process change, the most advanced EBD healthcare facility is still only a building that houses healthcare-related activities. In the modern age, healthcare is highly dependent for diagnosis and for treatment on the technologies that have been created to help people live longer. But the scientific approach to healthcare often leaves out the care portion; diseases are isolated and treated without paying attention to the fact that a patient is more than a sum of his or her ailments. The counterpoint to this view is patient-centered care.
Quality
Another factor fueling EBD inquiry is the recognition that the US healthcare system is failing to meet quality standards, that our system does not consistently translate knowledge into practice and apply new technology safely and appropriately2; and the recognition that the built environment has an effect on patients and their families, on staff, and on various outcomes. The Institute of Medicine (IOM) established a quality initiative in the late 1990s and subsequently published two seminal reports: To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001). These reports call for a system-wide reform of healthcare in the US.
ii
Family refers to two or more persons who are related in any way biologically, legally or emotionally. Patient and families define who is in their family.
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Attendance at the 18th National Forum on Quality Improvement in Healthcare3 in December 2006 revealed a plethora of stunning statistics about how dangerous our hospitals really are: Of the 37 million discharges last year, between 3% and 17% of the patients were injured. Chance of dying through error is somewhere between 1 in 300 and 1 in 700. Chance of experiencing an adverse event is 1 in 30. 10% of all patients get the wrong medication. For every 1,000 patient days, 3.5 patients fall; and the unlitigated cases cost $10K each. Last year, 90,000 patients died of hospital-acquired infections. Only 14-30% of staff comply with hand-washing standards. If we know there are certain design elements that contribute to a more efficient and effective healing environment, shouldnt we be building these into every new or renovated healthcare facility? We must, at least, ensure that we are not hard-wiring error into our built environment.
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Gordon Guyatt coined the term evidence-based medicine (EBM) in a published paper in 1992. In 1993, the Center for Health Design (CHD) was founded by a group of healthcare and design professionals. Their entire mission is to transform healthcare settings into healing environments that improve outcomes through the creative use of EBD. They have become the preeminent collector of all kinds of research and information on EBD, from the fields of evolutionary biology, neuroscience, environmental psychology, and psychoneuro-immunology (which is the effect of emotions on the immune system and psyche). Their vision is for healthcare design to contribute to health, rather than adding to stress. Shortly thereafter (in 1994), the Cochrane Collaboration was formed. This is a webbased meeting place for clinical review and central data repository that hosts the Cochrane Library, which contains information about more than 3,000 reviewed, randomized clinical trials from all over the world. (See www.cochrane.org .) The Collaboration employs a systematic review process to validate clinical trials. In 1997, the Center for Health Design published a report that compiled all available knowledge on the topic. At the time, the Johns Hopkins research team found that there were only 84 significant research studies. Roger Ulrich categorized the extant research into 5 areas: Access to nature, control, positive distractions, social support, and environmental stressors. The Center recognized a need to fill in many of the gaps, and began a comprehensive research agenda. In 1998, CHD partnered with the Picker Institute to study consumer preferences in healthcare settings. The results: consumers want a connection with staff; a place that fosters well-being, is convenient, accessible, confidential, private, demonstrates care for their families, is considerate of their current state, and is close to nature. When the Institute of Medicine (IOM) reported on improving the quality of care delivery (in the reports To Err Is Human in 1999 and The Quality Chasm in 2001), they identified six factors for best practices. These are patient-centered, timely, efficient (reduces waste), equitable (accessible to all), effective delivery of care, safe. All of these are EBD principles. The Center for Health Design initiated its Pebble Projects in 2000 to establish a group of peers measuring and sharing their specific outcomes regarding EBD applied to any renovation or new building project. Over 40 organizations have participated to-date. The hope is that the Pebble Projects will create a ripple in the healthcare industry and spur more rapid advancement of EBD principles. Roger Ulrich and Craig Zimring performed another meta-analysis of the data in 2004, and they found 600 studies available. Their meta-analysis also included the establishment of a 5-star rating system to classify which studies and results are most compelling and most strongly evidence-based, which have been updated and included in this report.
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EBD Timeline
Archie Cochrane: evidence-based research methods Planetree established
(1978)
2006 DoD Facility Planning Criteria & AIA Guidelines both recommend single-patient Inpatient rooms
1970
1980
2005
2007
Numerous professional associations (American Institute of ArchitectsAIA, Joint Commission on the Accreditation of Healthcare OrganizationsJCAHO, Center for Healthcare Effectiveness Research, American Society for Healthcare EngineeringASHE, and the Institute for Healthcare ImprovementIHI) take an active interest in EBD principles, and many have begun to include EBD recommendations in their professional standards and guidelines. The DoD Space Planning Criteria, for example, have recently changed to recommend single-bed inpatient rooms. In 2003, JCAHO began a process to revise their infection control standards. Joint Commission Resources published Infection Control Issues in the Environment of Care in 2005 as a resource for healthcare organizations to help their environment of care professionals to prevent as many hospital-acquired infections as possible. They advocate a multi-faceted approach, which recognizes the interdependence of processes, leadership, and the healthcare environment. JCAHO references AIA, ASHE and Center for Disease Control guidelines for controlling infection during construction. All agree on the need for a pre-construction infection control risk assessment. The 2006 Guidelines for Design and Construction of Health Care Facilities4, published by the American Institute of Architects and the Facility Guidelines Institute, suggests, but does not mandateiii, many features that have been studied in the EBD arena and proven to have a positive impact on patients, staff or facility/institutional resources. They, too, advise the early assembly of an interdisciplinary design team. Most of the major EBD
iii
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features that will be discussed later in this report are included in the new AIA Guidelines. EBD-supported standards that maybe be considered for the 2010 Guidelines edition include patient lifts, acoustic standards to ensure privacy and confidentiality, standards for surfaces and finishes to support infection control, and placement of hand-washing facilities. The 2006 Guidelines states Sustainable design, construction and maintenance practices to improve building performance shall be considered in the design and renovation of health care facilities. The sustainable design components include site selection and development, waste minimization, water quality and conservation, energy conservation, indoor air quality, and environmental impact of building materials. The Guidelines references the Green Guide for Health Care and the US Green Building Councils LEED Green Building Rating System. The results of the Pebble Project studies are being incorporated into the data repository held by the Center for Health Design, and will be used in the Robert Wood Johnson Foundation-sponsored update from CHD expected in the summer of 2007.
EBD Resources
Almost all EBD research has occurred in the private sector, with the vast majority of the work focused on the inpatient setting. Many organizations have been studying EBD for 10 years or more. A summary of the more seasoned EBD experts is provided below: Multiple academic centers exist to study evidence-based design and to further the research into this discipline. The Georgia Institute of Technology and Texas A&M University are widely regarded as the definitive authorities. Georgia IT is engaged in extensive research and meta-analysis of EBD hypotheses. Craig Zimring is on their faculty. Texas A&M has a Center for Health Systems & Design, sponsored by the Colleges of Architecture and Medicine. Both Kirk Hamilton and Roger Ulrich are on the faculty there. For a comprehensive compilation of EBD articles and research, see the Center for Health Design website (www.healthdesign.org). It contains rich details of both past and on-going Pebble Project research. CHER (the Coalition for Health Environments Research) recently became a part of the Center for Health Design. Their information is also available on the CHD website. (http://www.healthdesign.org/CHER/). The Robert Wood Johnson Foundation provides research grants in healthcare, in four particular areas of focus (including improving the quality of care). Like the Center for Health Design, RWJF publishes the results of their research. A link is available to RWJF from the Centers website.
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Healthcare Without Harm is an organization that promotes a safe healthcare environment, and encourages responsible use of materials. They have done a lot of research on toxins in building materials, and advocate toxin-free built environments. Their website is www.noharm.org/us/. The Green Guide for Health Care recommends guidelines for construction materials and furnishings with the objective of minimizing indoor air contaminants that are odorous, potentially irritating and/or harmful to the comfort and well-being of both installers and occupants. The Green Guide for Health Care is available for download from their website: www.gghc.org.
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Hospitals Doernbecher Childrens Hospital Portland, OR Woodwinds Health Center Woodbury, MN Genesys Health System Grand Blanc, MI
6
EBD Features Incorporated Family-Centered Care environment; Cancer Center for Children Patient- & Family-Centered Care; private patient rooms, family accommodations; holistic and alternative care Patient-focused philosophy; the hospital learned from early Operations mistakes http://www.planetree.org/about/welcome.htm Patient-focused care innovations: single-patient rooms, inclusion of family, access to nature, natural light, stress-reducing elements like music, art, etc. First hospital-wide Planetree affiliate http://www.healthdesign.org/research/pebble/ Infection control (single-patient rooms); relationship between patient acuity, time standards and productivity of nursing staff; Acuity-adaptable patient rooms, decentralized nursing stations, dedicated spaces for family. Acuity-adaptable, private patient rooms with patient, family & staff zones; access to natural light; barrier-free nursing stations; noise-reducing features; peaceful settings Infection control (HEPA in whole ED); [has also researched surge capacity issues] Ambulatory Practice of the Future (not yet built) Patient & Staff Safety focus; completely standardized rooms; integration of technology Ambulatory Care how attractiveness of waiting rooms affects perceived wait times and staff interaction quality
Planetree Affiliates
Mid-Columbia Medical Center The Dalles, OR Pebble Project Hospitals 7 Bronson Methodist Kalamazoo MI Clarian Hospitals Indianapolis, IN Dublin Methodist Hospital Dublin, OH
ER One Washington Hospital Center Washington, DC Massachusetts General Hospital Boston, MA St. Josephs Community Hospital West Bend, IN Weil Cornell Medical Center College New York, NY
MHS facility planners may want to visit some of these early adopters in order to see certain features in action and to discuss the realized outcomes and challenges before including particular EBD features or responses in MHS projects.
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Epidaurus Project and EBD Working Group The Epidaurus Project was born in 2001, led by CAPT Fred Foote, who engaged the academic community to identify the attributes of the hospital of the future that was patient- and family-focused. The MHS Office of Transformation has established a triservice, interdisciplinary EBD team with expertise in these subject areas. There is an OSD-HA EBD Group, consisting of clinicians, facility planners, and architects, whose mission is to promote, codify and institutionalize patient-centered and evidence-based design throughout the MHS capital facility landscape. The Epidaurus Project and the EBD Working Group together have identified MHS EBD principles and goals to guide the design and construction of the new hospitals in the National Capital Area (NCA) and other projects and to establish mechanisms to review EBD features and responses across the facility life cycle. EBD as it relates to DoD Space Planning Criteria When revised in 2006, the updated DoD Space Planning Criteria embraced many AIA 2006 recommendations, the highlights of which include: single-bed rooms, acuityadaptable rooms, decentralized staff support on inpatient units, and eliminating the use of curtained cubicles in the Emergency Department (i.e., replacing curtains with walls). QDR 8 Every four years, the Department of Defense is required to conduct a review of its operations and to articulate long-range (20-year) planning for the entire organization. In 2006, the MHS response to the Quadrennial Defense Review was the April 3rd Roadmap for Medical Transformation, which identified two initiatives relevant to this study: #8: Transform the Infrastructure and #17: Effective Patient Partnerships to Sustain the Benefit. Among other issues, QDR8 says that MHS will revise existing space and construction criteria to reflect use of accepted industry best practices and also refers to the need for all BRAC projects to be complete by 15 SEP 2011. The objective of QDR17 is to improve patient care, enhance patient satisfaction, and reduce the cost of healthcare by leveraging patient partnerships to achieve evidence-based healthcare outcomes.8 The Office of Transformation has established an interdisciplinary team to ensure that military treatment facilities (MTFs) comply with QDR17 recommendations. Several current Special Studies by Innova, VWI, and executive-level support by Martin, Blanck & Associates are sponsored by the Office of the Secretary of Defense for Health Affairs (which oversees TMA). OSD-HA Secretarys Memo The Assistant Secretary of Defense (Health Affairs), Dr. Winkenwerder, signed a memo on 22JAN07 requesting that patient-centered and evidence-based design principles be applied across MILCON construction projects. It said: I request that you apply patient centered and evidence based design principles across all medical MILCON construction projects. A growing
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body of research has demonstrated that the built environment can positively influence health outcomes, patient safety, and long-term operating efficiencies This memo (the full text of which is Attachment 3) recognizes, at the top levels of the MHS, the merit in evidence-based design and a patient-centered approach to healthcare. NCA Design When the BRAC decisions were announced on 13 May 2005, planning and programming teams began work in the National Capital Area (NCA) to create the Walter Reed National Military Medical Center at Bethesda and the new Community Hospital at Fort Belvoir as the two inpatient facilities of an integrated healthcare delivery system. The NCA projects have served as an EBD living laboratory for those EBD features and responses with both compelling science and a strong business case. Many EBD features and responses were included in the planning and programs for design for both projects, which are described more fully in Section III of this report. In January 2007, the Epidaurus Project and EBD Working Group began focusing their efforts on the design for both projects to ensure that the key EBD features were included. Communities of practice were engaged for those desired EBD features and responses not a part of DoD criteria, such as HEPA filtration and ceiling-mounted lifts. This work continues as a means to mitigate the risks associated with these innovations and to conduct return on investment analysis. This living laboratory experience obviously has broad implications for the MHS as a whole, and a sense of urgency has developed around sharing this report as a first step to inform the facilities community and as a means to further EBD application in other MHS projects by harvesting the current EBD science and NCA experience.
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Current Science
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Current Science
III.
The purpose of this section is to provide the reader with an overview of the EBD literature, recommend EBD features and responses, and suggest future MHS studies. This section is organized to correspond to the EBD Principles and Goals identified by the MHS in order to facilitate a practical application of the findings in this report. A limitation of this report is that almost all of the EBD research has been conducted in the inpatient environment, with little specific research in the ambulatory care setting or dental community, two healthcare settings of great interest to the MHS. However, many of the Recommended EBD Features and Responses would seem to have generalized applicability in any settinga premise that should be tested. Literature Review and Key Information Sources Thousands of EBD articles exist. In the past three years, a number of comprehensive evidence-based design reviews of the literature have been conducted with great success. The key articles that were associated with improved patient, staff and resource outcomes (as identified in those comprehensive reviews) were further scrutinized for this report. More recent EBD articles were also used. Comprehensive Reviews of the EBD Literature 2004 - The Role of the Physical Environment in the Hospital of the 21st Century The first comprehensive review, published in 2004, was funded by The Robert Wood Johnson Foundation and was conducted by Dr. Roger Ulrich from Texas A& M University and his team, in partnership with The Center for Health Design. They reviewed more than 600 studies, finding rigorous research that linked the physical environment to patient and staff outcomes.9 The Center for Health Design then translated the literature review into a scorecard that ranked the strength of the literature using a star system, with 5 stars meaning a great deal of research has been conducted and one star ( ) indicating little research conducted. These scorecards are divided into four categories: Patient stress, staff stress, patient safety, and quality, and are shown below.10 Patient Stress Scorecard
Reduce stress, improve quality of life and healing for patients and families
Reduce noise stress Reduce spatial disorientation Improve sleep Increase social support Reduce depression Improve circadian rhythms Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients and families Provide positive distraction Patient stress (emotional duress, anxiety, depression)
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Quality Scorecard
Improve overall healthcare quality and reduce cost
Reduce length of patient stay Reduce drugs (see patient safety) Patient room transfers: number and cost Re-hospitalization or readmission rates Staff work effectiveness; patient care time per shift Patient satisfaction with quality of care Patient satisfaction with staff quality
The score cards provide an important visual tool that summarizes the EBD science strength relative to resolving key issues. Work is underway at the Center for Health Design to view this body of science through another lens, by asking, What are the top ten EBD features and responses?11 Another key question for future consideration might be, If you only had limited funds, which EBD investments will give you the greatest return?
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2005 The Hospital Built Environment: What Role Might Funders of Health Services Research Play? The Agency for Healthcare Research and Quality contracted with the Lewin Group, Inc., to address the relationships between the hospital design and construction and the factors that influence patient and staff safety and outcomes. Their findings are consistent with those of Ulrich.12 2006 Improving Healthcare with Better Building Design The Center for Health Design, with Sara O. Marberry as editor, published this EBD primer book as a part of the American College of Healthcare Executives Management Series. Ulrich and his original team, along with some new contributors from the interior design, environment and business communities provided this comprehensive resource on the subject by updating and validating many of the findings discussed in the 2004 literature review cited above.13 2006 Designing for Quality: Potential for Facility Design to Elevate Patient Outcomes The Healthcare Advisory Board published a Business Brief from their Innovations Center, in which they provide a framework for identifying those features that have a positive impact on both financial performance and clinical outcomes, and recommend the following as A Good Bet: - Private rooms - Standardized room design - Efficient unit layout - Ceiling lifts - Natural lighting14 2006 -2007 The Center for Health Design Research Papers Dr. Anjali Joseph, Director of Research, and members of her team at The Center for Health Design have produced several EBD subject-focused review articles on noise, infection, light and the workplace, which update Ulrichs findings for each topic. These are: Sound Control for Improved Outcomes in Healthcare Settings 15 - January 2007 The Impact of the Environment on Infections in Healthcare Facilities 16 - July 2006 Impacts of Light on Outcomes in Healthcare Settings 17 - August 2006 The Role of the Physical and Social Environment in Promoting Health, Safety and Effectiveness in the Healthcare Workplace 18- November 2006 2007 Anticipated Reviews The Robert Wood Johnson Foundation recently funded Dr. Zimring and the Center for Health Design to complete a second comprehensive meta-analysis article, which will incorporate many of Dr. Josephs findings in the articles cited above and will be published in the summer of 2007.19 Other Key Information Resources Building environmentally responsible hospitals represents another EBD facet. This goal is translated into sustainable design principles that result in healthier healthcare
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buildings.20 The Green Guide for Health Care is a metric tool for evaluating health and sustainability of building design, construction, maintenance and operations for the healthcare industry. The self-certifying system is modeled after the U. S. Green Building Councils (USGBC) LEED rating system.21 Recommended EBD Features and Responses For each goal, recommendations are made with regard to the EBD features and responses that would best support achievement of the desired outcomes. EBD features include actual elements of the built environment, while EBD responses include other facility life cycle management and performance activities that augment EBD practice or building material choices. Design always requires choices mitigated by many circumstances, not the least of which is the budget. However, many EBD features can be achieved through good design and do not require an additional front-end investment; these are also included for consideration. Some of the recommended EBD features are not currently supported by DoD criteria. Each one deserves further scrutiny and perhaps a return on investment (ROI) analysis. A simple scheme is provided to qualify the recommendations: An asterisk (*) at left indicates those EBD features supported by both compelling science and a strong business case. Future Study Opportunities At the conclusion of each goal discussion, potential MHS study opportunities are identified, including many with a unique military focus. These are gathered in a quickreference list as Attachment 4.
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Improved patient satisfaction and, potentially, patient length of stay by optimizing patient nutrition with family support. Improved patient satisfaction with potential shorter lengths of patient stays with improved patient rest and sleep. Improved patient satisfaction by providing adequate parking convenient to building entrances and patient services.
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Waiting Rooms and Lounges. Moveable furniture in small, flexible groupings with a variety of seating to accommodate the widest range of patients is recommendedrather than the military dress-right-dress approach used in many MHS facilities today. The goal is to create a space that looks more like a living room than an institutional environment.
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Signage using common language and logical room numbering is also important. Ulrich et al (2006) found more than 17 studies examining hospital wayfinding, but hospital building complexity and variation made it difficult to isolate single influences of design on wayfinding performance or patient and visitor stress.33 A recent Washington Post article described literacy problems that further complicate signage selection and provision of wayfinding information. Patient-friendly navigation signs using icons and pictures have been helpful to non-English speakers and others challenged by complex medical terminology.34
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Privacy Index Rating 95-100% of conversations partially overheard but not understood outside the space 80-95% - conversations may be heard, are only partially intelligible 60-80% - most conversations will be overheard and intelligible to unintended listeners Less than 60% - all conversations can be fully overheard and understood
Recommended Hospital Spaces Admitting areas, areas where patients discuss their personal health, psychiatric and psychological testing rooms, hematology labs, exam rooms, etc. Enclosed single-patient rooms Not desired
Normal Marginal/Poor
No Privacy
Not desired
Current AIA Guidelines recommend that public circulation and staff and patient circulation should be separate wherever possible and that private alcoves or rooms should be provided for all communication concerning personal information relative to patient illness, care plans, and insurance and financial maters. Acoustic privacy is an area of interest for the 2010 AIA guidelines and acoustic engineers are working with the guidelines committee.
Recommended EBD Features or Responses * Single-bed Rooms. Patient privacy and confidentiality is best supported in a single-bed room. * Use High Performance Sound-Absorbing Acoustical Ceiling Tiles Install high-performance sound-absorbing acoustical ceiling tiles to prevent sound from bouncing off the ceiling into adjoining spaces. Attention should be paid to surrounding structures (room and corridor walls and ductwork) as well as to tile cleanability. Avoid Open-Plan Cubicle Curtained Admitting, Examination and Treatment Spaces. Ensure that admitting, exams and treatments occur inside walled rooms. Current DoD Space Criteria includes open-plan rooms with cubicles separated by curtains: e.g., in the post-anesthesia care unit, primary care clinic treatment rooms. A ROI analysis is needed. Provide an Adequate Number of Private Consultation Rooms Ensure that there are walled rooms for providers to conduct meetings with families and in public areas like reception and waiting rooms where private information may be discussed. This is currently supported by DoD Space Criteria. Avoid Physical Proximity between Staff and Visitors Ensure that admission and reception areas are designed to avoid physical proximity between staff and visitors to minimize overhearing confidential telephone conversations and discussions.
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Provide Windows in Staff Break Rooms Although more research is needed, it appears that maximizing access to natural light reduces staff stress and improves both circadian rhythms and staff satisfaction.
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Identify patient outcome improvements and quantify these. Identify family nutrition support requirements. Conduct a return on investment (ROI) analysis to request approval and funding for additional building features.
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occupants.44 The Green Guide draws upon several sources for these guidelines including: the South Coast Air Quality Management District (SCAQMD) Rules #1168 and #1113, Green Seal Standard GC-36, California Prop 65, California Air Resources Board List of Toxic Air Contaminants, and California 01350. Recommended EBD Features or Responses Use 100% Lead- and Cadmium-Free Roofing, Wiring and Paint Install Low-Mercury Florescent Lamps Use Materials that are Low Emitters of VOC (volatile organic compounds) and PFC (perfluorocompounds) Use Materials with no PBDE (polybrominated diphenyl ethers) or Phthalates Use Materials with No Added Urea-formaldehyde Resins. Minimize use of furniture and furnishings that contain: PBDE, PFOA, urea-formaldehyde, phthalate, and plasticizers. The Green Guide recommends that at least 40% of the annual purchases (by cost) meet the standards (i.e., contain no more than one of the compounds listed above). Future Study Opportunities Green Guide Adherence across Each Phase of the Facility Life Cycle Performance and Management Model The degree to which the Green Guide recommendations are adhered to in the MHS at each phase of the Facility Life Cycle Management and Performance Modelbut particularly in the sustainment phaseis not known.
MHS hospitals that receive war wounded have been particularly challenged by antibioticresistant acinetobacter baumannii, klebsiella pneumoniae, pseudomonas aeruginos and
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staphylococcus aureas infections in addition to the more common HAI. Research is underway to understand the high rate of current infections associated with casualties in the war on terrorism.47 Three improvement goalsone for each potential source of infectionare provided below, along with additional goals to reduce medication errors, prevent patient falls and to reduce noise stress and improve speech intelligibility. Expected patient, staff and resource outcomes associated with achieving the six goals associated with improving the quality and safety of healthcare include: Reduce the number of HAI as well as associated patient morbidity, mortality and cost. Reduce the number of and associated costs for staff with HAI. Decrease the number of medication errors, patient falls and associated costs. Improve patient sleep and rest by achieving WHO-recommended noise decibel levels.
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There are reports of some non-healthcare institutions using ultraviolet germicidal irradiation (UVGI) to mitigate airborne transmitted viruses. Menzies et al (2003) reported on the effects of UVGI on drip pans and cooling coils within ventilation systems for office buildings of 771 office workers in Montreal. The results showed 99% reduction of microbial contamination on irradiated surfaces within the ventilation systems with substantially fewer work-related mucosal, respiratory and overall symptoms.53 No Center for Health Design Pebble Projects are currently studying UVGI. Ventilation is another important means to control the level of pathogens in the air. A recent study by members from the Imperial College of London (2007) in 8 hospitals in Lima, Peru, found that old hospitals with high ceilings and large windows (with open doors and windows) averaged 40 air exchanges per hour, which reduced the probability of institutionally-acquired TB infection using the Well-Riley equation to 11% as compared with 39% of patients cared for in mechanically-ventilated rooms with 12 air exchanges per hour.54 Current recommended AIA and DoD ventilation rates vary across different patient-care areas of a healthcare facility.
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Conduct a return on investment analysis to request approval and funding to add additional HEPA filters, as appropriate. HEPA Efficacy in Asymmetric Warfare: Biological Agents The military has a unique role during contingency operations. Recent employment of asymmetric warfare techniques increases the potential for use of other technologies, such as dirty bombs with biological agents. Study is needed to understand the role hospital HEPA environments might play in successfully responding to such contingencies. Evaluate Ventilation Exchange Requirements for Severely Immunocompromised Patients Examine the current criteria for ventilation, particularly for severely immunocompromised patients, in the form of air exchange rates as a second variable, using the same study process described for HEPA filtration. Use of UV to Mitigate Airborne Transmitted Viruses The military has particular interest in understanding any positive role that UV technology might play with regard to reducing the number of airborne transmitted viruses. In the past, basic training environments have been plagued by varicella and influenza outbreaks, and world-wide missions make warriors vulnerable to SARS and other viruses. Infected warriors may require hospitalization, which further enhances a need to understand the role UV plays in mitigating airborne transmitted viruses in MHS facilities.
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Imaging rooms (in [nearby for MRI] rooms where staff physically handle patients) PT and OT (in each treatment space) Nursery (one per eight infant stations) NICU (within 20 feet of each infant station in multiple-station areas) Microbiologically-contaminated surfaces represent another means by which infections are spread by contact. High-contact surfaces need to be cleaned and disinfected more frequently than minimal contact surfaces, which means that the selection of materials for floors, walls, ceilings, furniture, furnishings and equipment with regard to ease of cleaning is a key consideration. According to Collins (1988), the number and type of organisms on a surface depends upon: the number of people in the environment amount of moisture present amount of activity presence of material capable of supporting bacterial growth rate at which organisms suspended in the air are removed and type of surface and orientation (horizontal or vertical), with counts from smooth intact walls and ceilings with lower counts.57 Copper is germicidal; surfaces have been shown to actually decrease the number of bacteria over time. Brass (a copper alloy) doorknobs disinfect themselves in about 8 hours; stainless steel and aluminum never do. (And the more they tarnish, the quicker they kill bacteria!) Using copper or brass for door handles, faucets, and other highcontact surfaces therefore may be an effective way to minimize the spread of infection and should be studied in healthcare environments as a means to decreasing HAI transmitted through contact.58,59
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However, the verdict remains out on the EBD features and responses most likely to contribute to the reduction of patient falls. Many researchers are focused on mitigating the fall risk associated with unassisted patients moving from the bed to the bathroom, through the so called, no grab zone. Some of the EBD strategies under scrutiny include: Locate the bathroom on the same wall as the head of the bed, with grab rails from the bed to the bathroom for patients to hold onto as they steady themselves. Use a pod concept of design to increase nursing personnel observance of and proximity to the patient. Use single-patient rooms, providing significant space for family members who can assist patients in their movement. Place and adequately size bathroom doors to facilitate patient movement, especially when encumbered by equipment, such as IV poles. Use flooring materials with less slippery qualities.
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patient outcomes as part of the transition planning activities for the NCA projects. Another feature to study might include the use of overhead cabinets versus mobile supply carts. An ICU unit under renovation in the current WRAMC will include decentralized support and could be used for this study.
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* Install High-Performance Sound-Absorbing Acoustical Ceiling Tiles This type of tile shortens reverberation times and reduces sound propagation thereby speeding the decay of sound.74 These tiles should be used in all new construction and to replace existing tiles during routine facility sustainment activities.iv Remove Loud Noise Sources Typical offenders include overhead paging and personal pagers. Locate Noisy Equipment Away from Patient Rooms The most notorious equipment offender is the ice machine. Ensure All Patient Care Rooms Have Walls that Extend to the Support Ceiling Many patient care areas include multi-patient spaces, which are separated by a curtain very common in the Primary Care Clinic Treatment rooms and Post Anesthesia Care Units. For all of the reasons described above, this creates a noisy environment, which may significantly contribute to poor patient outcomes. The walls need to extend all the way up to the structure above in order to fully block the noise between patient rooms and public spaces (e.g., hallways). Use Carpet and Rubber Floors Where Appropriate Carpet absorbs sound, but this must be weighed with infection control issues in areas where the risk of spilled patient fluids exists. Hallways may be a reasonable area for carpet use.
EBD Principle 3: Enhance Care of the Whole Person (Contact with Nature & Positive Distractions)
The central tenet of EBD is patient-centered and family-focused care. Patients and their families do not spend time at hospitals because they are bored and seeking entertainment. They are there because they are ill or injured or concerned about preventing illness and ultimately, improving their health. They enter an environment that is often confusing,
iv
In response to questions about cleanability: Rather than cleaned, most ceiling tiles just get replaced on a regular sustainment cycle.
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uses a separate language, and in which painful procedures occur and frightening and overwhelming information is given. Expected patient, staff and resource outcomes associated with achieving the EBD goal associated with decreasing patient and family stress include: Support healing with less depression, alleviate pain, improve sleep and circadian rhythms; all of these result in decreased use of pain medication and patient lengths of stay as well as increased patient satisfaction.
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anxiety and confusion for a broad range of patients, to include those being mechanically ventilated, women undergoing Caesarean delivery, mothers caring for NICU infants and elderly patients undergoing elective hip and knee surgery.85, 86, 87, and 88
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Floor Lift 1. Decide if lift is needed 2. Decide which lift is needed 3. Go get the lift 4. Hopefully can find it and dont have to wait 5. Move lift to patient room 6. Move the furniture out of the way 7. Position lift 8. Lift patient 9. Move lift out of the way 10. Care for patient 11. Return lift to its home 12. Go back to patient or on to next patient
Ceiling Lift 1. Decide if lift is needed 2. Put sling under patient 3. Lift patient 4. Care for patient 5. On to next patient
Many of the barriers cited above are removed with the use of ceiling-mounted lifts. Research has demonstrated a reduction in staff injuries and associated medical and compensation costs. One hospital was able to decrease the number of staff injuries associated with patient handling of ICU and neurology patients from ten over 24 months to three over 36 months after ceiling-mounted patient lifts were installed. The result was an 83% reduction in annual costs associated with patient-handling injuries.94 An extended care facility in British Columbia found a 68% reduction in compensation costs in a unit with ceiling mounted lifts versus a 68% increase in compensation costs for another unit without such lifts over the same time period.95 In the British Columbia study, an assumption about pre-intervention injury costs, economic pay-back for the ceiling mounted lifts was projected to be 0.8 years, given increased injury costs, or 2.5 years if associated injury costs remained stable.96 Legislators are also interested in the problem. Representative Conyers (D-MI) has introduced HR 378, Nurse and Patient Safety & Protection Act of 2007, which specifies a series of actions and standards to reduce injuries to patients and staff. Section 3 of the Bill directs health care facilities to ensure that safe lifting mechanical devices shall only be used by registered nurses.97 Recommended EBD Features and Responses * Install Ceiling-Mounted Lifts Ceiling-Mounted Lifts should be provided in those rooms where patients are likely to require lifting or movementsuch as ICU/IMCU rooms, Operation Rooms, Emergency Department Trauma Rooms, and some portion of medical/surgical and pediatric rooms as part of a comprehensive Zero-Lift program. Use Softer Floors Consider the use of softer floors in those areas where lengthy staff standing routinely occurs. Redfern and Cham (2000) has shown a decrease in lower extremity and low back pain for workers who are on their feet when standing on softer floors, such as rubber.98
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Ergonomically Evaluate Work Areas Some specific work areas associated with staff injury include operating rooms, where staff movements are constrained and prolonged, and at computer work station areas for all healthcare staff members with a focus on posture, computer readability and visual fatigue.99 Future Study Opportunities Reduce Patient and Staff Injury Incidence and Severity Inclusion of the above-recommended EBD features represents just one element of a comprehensive MHS Zero-Lift policy. Such a program should be developed and then studied with regard to the costs of mitigating injuries contrasted with negative patient outcomes to include injury and associated increased care costs and litigation, as well as injured staff costs associated with medical care, compensation, sick days, restricted duties, and retention. Ergonomic Evaluation of Work Areas There are many healthcare environment areas that require further ergonomic evaluation and study to understand what features in the built environment will reduce staff injury. Optimal height of work surfaces within nurse stations (sitting versus standing), for example, should be examined. Needle Stick Injuries Needle sticks are another common staff injury, which universally require medical evaluation and very often, prophylactic treatment to avoid potential life-threatening consequences. The physical environment may play an important role, specifically as it relates to the location and use of sharps disposal boxes within a standardized room configuration.
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ICU/IMCU/LDR beds and every 4-8 acute medical/surgical, pediatric and obstetric beds. The anticipated result is that the nursing team will remain proximate to the patients, thereby facilitating more time in direct patient care, which will result in fewer patient falls and medication errors and less staff fatigue and greater work satisfaction. However, Joseph (2006) suggests that attention must be given to the change in staff interactions and consequent staff communication effectiveness and satisfaction associated with this decentralized process.103 Recommended EBD Features and Responses Decentralize Staff Support Spaces Locating staff support spaces such as supplies and charting space next to or in patient rooms should reduce staff walking, providing more patient care time and greater staff satisfaction. However, the space should be designed with privacy to minimize distractions that can result in errors. Provide Windows in Staff Break Rooms As is true with patients, access to natural light may help staff with circadian rhythm adjustment, thereby improving staff fatigue. Natural light costs nothing once the window is provided.
Impact of Natural Light versus Artificial Light on Staff Mood and Performance Some studies have shown that staff exposure to natural light has a positive impact on their work experience. More work is needed to understand the importance of natural light to staff and specifically any impacts on staff performance, especially as the healthcare workforce ages. Impact of Different Lighting Conditions on Staff Work Performance Providing quality healthcare involves multiple complex tasks: medication preparation and administration, conducting invasive and non-invasive procedures, and documenting care. Several studies summarized in Josephs 2006 article on light showed that exposure to intermittent bright light during the night shift is effective in adapting circadian rhythms of night-shift workers.104 Additional research is needed to understand the ideal light level for a variety of error-prone tasks by workers of varying ages. Future Study Opportunities Decentralized Staff Support Areas Planned for New Community Hospital at Ft. Belvoir. Decentralized staff support is planned for the New Community Hospital at Fort Belvoir and some units at the New Walter Reed National Military Medical Center at Bethesda. The decentralized support includes: charting, clean supplies and clean linen, soiled collection and automated medication dispensing for routinely scheduled medications. Efforts should be made to understand the impacts of this investment on patient and staff outcomes, to include staff fatigue. Patients may provide important information to consider in design. In addition, there may be increased pharmacy and logistic staff costs associated with packaging and distributing medications and materials to more locations on each unit.
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Supplies Location Providing supplies in the patient room can be effected without interrupting the patient by having cabinets in the corridor walls of the rooms that open from both inside and outside the room. The effects on caregiver and logistical staff exhaustion as well as on patient satisfaction could be measured.
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at WRAMC and NNMC and could be studied with regard to team effectiveness and patient satisfaction. Smaller Unit Size to Foster Interaction DoD Space Criteria provides specific recommendations for the number of beds by specific unit type. At the New WRNMMC, a number of the planned medical/surgical units are larger than the DoD recommendation not to exceed 36 beds because of funding and physical constraints. A pod design concept with decentralized support was planned to mitigate some of the challenges inherent in large units. Likewise, many civilian hospitals also are building large units (40 beds) with pod support. Understanding and applying civilian lessons learned about team effectiveness with regard to this approach is an important transition planning undertaking. Obviously, optimal communications and logistics processes must also be combined with changes to the built environment.
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A hospital in the Bronx has piloted a program to quiet one floor, and their decibel levels have been reduced by 28%. In addition the sound-absorbing ceiling tiles and curtains, the program relies on posters, buttons given to each patient, staff and visitor and proper maintenance of potentially loud equipment.66 The educational component probably has as much impact as the environmental measures.
EBD Principle 5: Design for Maximum Standardization, Future Flexibility and Growth
Most military healthcare facilities remain in the DoD inventory for fifty years. Consequently, each Medical MILCON investment requires a dual approach to first satisfy the anticipated healthcare demand when the facility opens and then to anticipate those aspects of healthcare delivery most likely to change, for which future alterations and additions may be needed. Most health care facilities experience seven or more remodels or changes during the life of the facility.109 Careful stewardship of limited MHS infrastructure resources is the focus of this EBD principle. MHS facilities should be designed for flexibility best supported by the concepts of expandability (taking a long-range view) and adaptability (adjusting quickly to immediate needs). The quality of expandability simplifies adding a new service or expanding an existing service. Design concepts to achieve this goal include: Create a circulation network that establishes growth patterns. Place high-tech services (e.g., imaging) on an exterior wall. Vertically stack services that are likely to expand; for critical services, provide a departmental layout with a clear expansion sequence (e.g., linear, cluster, modular). Plan for plug-in mobile units; locate major immovable elements so as not to inhibit expansion; size structural systems for vertical expansion (including placement of mechanical units on roofs). Design building systems for ease of expansion. The quality of adaptability could be viewed as a more frequent need to respond to fluctuations in workload, acquisition of new equipment or special events. In this case rooms may simply be re-assigned and/or minor-to-moderate renovation may be required to modify walls, building systems or finishes. Design concepts to increase adaptability include: Using standard modules; ensure that fixed elements (elevators, mechanical/electrical rooms) do not encumber open space. Locating soft space where high-tech rooms will be needed; share or swing space with low utilization, adopt design concepts to accommodate potential/expected operational changes (e.g., use a standard private patient room for all acute care beds medical/surgical, pediatrics, and psychiatry). Using an open space plan with moveable partitions, work spaces and equipment for general office areas, laboratories, and pharmacies; size structural bays to accommodate varying room configurations; design building systems for access and space for additional systems; zone building systems (this allows shut down for repair or to conserve energy without disrupting other areas).
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Using building systems and equipment that can be moved and/or re-configured (mobile partition and shelving units, component headwall systems, etc.). Providing additional fixtures so equipment can be added without construction (additional electrical and communications outlets, stubbed-in plumbing so that an office can become an exam room). Expected patient, staff and resource outcomes associated with achieving the two EBD goals associated with designing for maximum standardization, future flexibility and growth include: Improve patient satisfaction, quality of care, and staff efficiency, as well as all associated costs by using acuity-adaptable rooms to decrease patient transfers. Improve patient satisfaction, quality care and clinical outcomes and staff efficiencies by creating care centers which collocate multidisciplinary care resources for unique patient populations. Reduce resources required to support episodic healthcare missions by ensuring that public spaces are designed to anticipate MASCAL, health fairs, mobilization and other military-unique missions.
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DoD Space Planning Criteria provides acuity-adaptable rooms as an option. Early planning work for the new NCA facilities engaged the nursing experts, who considered this option. Many of the team held the view that the status quo should remain, which includes the traditional intensive care, step-down and acute medical/surgical units. In general, critical care nurses only want to care for high-acuity patients, and medical/ surgical unit nurses are reluctant to care for this same group. After much discussion, particularly around staffing models and staff training, the decision was made to combine intensive care and step-down care in a single intensive care/intermediate care (ICU/IMCU) room. The nurses reasoned that both ICU and step-down nurses require much of the same training and expertise, so instead of moving the patient to a step-down unit as the patients condition improved; they would adjust the amount of staffing. Most RNs and their care team can support 1-2 ICU patients or ~3-4 step-down patients, depending on patient acuity. Schroeder (2007) found one 70-bed, acuity-adaptable, zerotransfer model that abandoned their approach after 12 months because of an inability to find staff cross-trained across the entire spectrum from ICU to medical/surgical acute care. They are now using the model planned for the NCA, where ICU nurses care for the highest acuity patients and patients experience only one transfer to acute services from the ICU. Still, focused transition planning will be necessary to ensure success in the new NCA facilities. Recommended EBD Features and Responses Use Acuity-Adaptable Rooms for Combined ICU/IMCU Care For the most part, this feature is only appropriate for medical centers that care for a large number of patients with high acuity. Future Study Opportunities WRAMC ICU Renovation A renovation project is planned for the existing WRAMC that will incorporate many of the EBD features described, including acuity-adaptable rooms. Patient and staff outcomes should be studied as part of the transition planning for occupying the New WRNMMC and the new Fort Belvoir Community Hospital.
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are what really constitute a healthcare organization. Mohr et al (2004) defines a clinical microsystem as a group of clinicians and staff working together with a shared clinical purpose to provide care for a population of patients that shares common core elements: focused type of care, clinicians and staff with the skills and training needed to engage in the required care processes, a defined patient population and a certain level of information and technology to support their work.113 When John Reiling, President and CEO, led the St. Josephs Community Hospital of West Bend, Wisconsin in their replacement facility design that incorporated many EBD features to improve patient safety, he concluded that one of the critical measures of design success was to ensure that the design kept vulnerable populations in mind.114 Nothing in DoD Space Planning Criteria precludes using a care center approach in planning, programming and design. However, it remains critical that representatives from each component of a clinical microsystem collectively envision the care center and the patient services to be provided. This approach was used in the planning for the NCA facilities, made even more complicated by the fact that the NCA will be a regional integrated delivery system, with two locations for many of the care centers. Many hospitals have embraced the hospitality industrys concierge approach to improve patient satisfaction with services. Designing a central location for patient drop-off or entry combined with staff available to meet and assist patients and their families is an EBD feature that supports this concept. Patient focus groups coordinated by the National Military Family Association as part of the design planning for the new NCA facilities strongly stated their desire to enter at a central location and be greeted by knowledgeable staff, rather than the side and back doors through which they perceive their present entry.115 Hospitals provide critical services during times of national crisis and during mass casualty events. Good hospital design always considers these hopefully rare, but important circumstances. This is particularly necessary in military healthcare, because of the inherent physical risk associated with military missions along the continuum of warfare, including the more routine tasks, such as training warriors. There are many recent events that remind us that the hospitals physical environment plays a critical role.
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Future Study Opportunities Examine Existing Care Centers for Positive Physical Attributes A number of care centers exist in NCA facilities today, such as Breast Cancer Care. A qualitative analysis about the positive and negative physical aspects of these existing centers that engages both staff and patients may provide important information to consider in design and transition planning. Examine the Use of Flexible Public Spaces to Support Multiple Missions, some of which may be Military Unique There has been no systematic review of how the facility design supports multiple care mission requirements, such as MASCALs and the associated patient, staff and resource outcomes, as a consequence. Table top exercises using recent contingency events such as the 9-11 strike on the Pentagon should be simulated with the planned designs for both NCA facilities.
In summary, most of the EBD features that are strongly supported by the literature are being incorporated into the designs for the new military medical facilities within the National Capital Area. DoD Space Criteria have already incorporated the most impactful EBD feature: the use of single-patient bed rooms. Adoption of other EBD features at facilities within the MHS portfolio will require both further studies (specific to the MHS populations) and cultural transformation.
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IV.
Commissioning
Transition Planning
Construction Design
Programming
Figure 2. EBD can be applied at any stage within the cycle for all kinds of projects.
The Facility Life Cycle Management and Performance Model phases exist for the whole range of facility projects, from Medical MILCON through renovation and life and safety upgrades. Measures of success exist for each phase. Intensive efforts are currently underway to modify the historic linear approach depicted, in order to shorten the existing
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timeline to realize a new facility, primarily through overlapping the work in the planning, programming, design and construction phases. EBD activities exist in every phase of the Facility Life Cycle Management and Performance Model, not just the design phase, as many people think. The focus of this section is to highlight the EBD activities associated with each phase of the model, by first briefly defining each phase and then providing an EBD activity checklist.
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Are there changes in patient capacity or throughput which are deviant from the norm or that you want to improve? (e.g., length of stay, cost per admission) Are MTF healthcare delivery services fragmented and inefficient today? Will a patient-focused care center approach be used? Cultural transformation, led from the top, underpins every successful EBD experience. Are all of the key stakeholders engaged? Each problem requiring resolution may need a unique team. Are patients and their family members represented in this effort? Does the vision and mission statement reflect the desired future state? Potential Solutions What EBD solutions exist for the identified problems? What clinical and business processes require reengineering? What cultural transformation is necessary? How You Will Measure Success What metrics are used today to measure the problems requiring resolution? Are the metrics adequate to measure success at a national level? What additional metrics are needed? Pay particular attention to the financial quantification of resource improvements. (See Business Planning, below.) Have you identified patient, staff and resource outcome targets that will be realized as a consequence of a comprehensive EBD approach?
Business Planning
Business Planning Definition Business planing reflects the current and strategic state in terms of costs and revenues. The MHS requires all MTFs to use a deliberate Strategic and Business Planning Process, as summarized below. MHS MTF Strategic & Business Planning Process 116 Analyze Market Understand Demand Evaluate Performance Determine Capacity Coordinate HC Delivery Plan Develop Action Plans Assess Financial Impact Submit MTF Plan to OSD/HA Monitor Plan Performance However, while strategic plans look out 5-10 years, the MHS business plans cover only two years, and, as such, provide only limited value to the facility planner. EBD features that represent an initial design or construction cost in excess of current DoD criteria, as well as those EBD features that seemingly cause increased sustainment costs, may require a return on investment analysis (ROI) to demonstrate the ultimate
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savings over the facility life cycle. Readers are strongly encouraged to read Chapter 7, The Compelling Business Case for Better Buildings in Improving Healthcare with Better Building Design. The authors use a hypothetical 300-bed project, the so-called Fable Hospital, to demonstrate how to outline first the incremental costs associated with creating a new building and then the financial impact of design decisions.117 Using the Fable Hospital approach, a notional sample of such an ROI associated with the goal of reducing hospital-acquired infections at the New Fort Belvoir Community Hospital is provided below. Return on Investment Analysis Incremental Costs
EBD Features Single patient rooms with conveniently placed sinks and dispensers Additional 99.97% HEPA filters in ICU, ER treatment room and one 6-bed med/surg Pod (2 airhandling units) Additional Costs None current DoD criteria $50,000 $30,000 initial $20,000 annual ops costs Calculations
Initial cost = $15K X 2 = $30K Increased operating cost = $4K/unit/year X2 = $8K Filter replacement = $6K/unit/year X2 = $12K annually Total $50K in the first year
Business EBD Questions/Activities Checklist Has an ROI for desired EBD features been completed to include all incremental costs and a financial impact? This may be an important step even for those EBD features currently included in DoD facility programming, design and construction criteria as a way of estimating the future resource impacts.
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Facility Master Planning EBD Questions/Activities Checklist What EBD features are lacking in existing healthcare facilities? Inventory current facilities and complete an EBD assessment. What EBD features are included in future projects? Are the right stakeholders involved? Does the EBD ROI require refinement?
Transition Planning
Transition Planning Definition Transition planning underpins all projectsfrom life safety upgrades to renovation and MILCON projectsby defining the plan for how an organization moves (literally and figuratively) from the current state to the future state. Good transition planning begins the moment a decision is made to pursue a project and continues through post-occupancy evaluation in the sustainment phase. There is an extensive transition planning body of literature, but at a minimum, the step-by-step process to successfully realize all of the needed changes should include: New policies and procedures, staff education and training, equipment and building familiarization, a communications plan, a patient move plan and much more. Transition Planning EBD Questions/Activities Checklist What is the transformational theme and leadership plan that will frame the communications plan? What EBD features need to be highlighted in transition planing? Who are the key stakeholders to involve in EBD feature transition planning? Are specific resources needed to facilitate EBD future transition planning (e.g., mockup or virtual rooms)? Visit facilities that have used the EBD features planned for your new or modified facility.
Project Planning
Project Planning Definition Project planning represents a detailed concept of operations for each clinical or administrative area, which includes: - Mission statement - Scope of services, training and research - Work volumes - historic compared with future - Staffing - historic compared with future - Key operating assumptions and parameters - Desired adjacencies - Desired layout and workflow - Major equipment Good project planning involves the key, multidisciplinary stakeholders who best understand current operations for each hospital area and, critically, can envision the
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future with regard to their discipline. Surgeon General-appointed consultants provide an additional source of information about future trends and healthcare and administrative practice changes for their areas of expertise that will impact the facility infrastructure. Project planning also considers the project schedule, which is particularly important in retrofit projects that require moving services to a temporary location in order to accomplish the work. Visioning sessions are often a helpful means to clarify the message, image, brand or theme and can be used to identify expected patient, staff and family amenities and to translate those attributes into the built environment. An afternoon visioning session was held for the interior design of the new community hospital at Fort Belvoir on June 8, 2007, preceded by a morning of presentations about EBD. With 70 stakeholders in the room, the architects and designers found the session extremely useful, resulting in a message of Caring for Our Own as the theme for the new hospital. Project Planning EBD Checklist Is a visioning session important? What EBD features are included in the project? What is the science that supports each EBD feature? Have these approaches been vetted with TSG consultants? How well does the DoD Space Planning Criteria support the desired EBD features? How do EBD features impact all aspects of the concepts of operation? What clinical or business re-engineering efforts are needed to maximize the facility EBD features? What outcome metrics will be used to measure success?
Programming
Programming Definition Using the DoD Space Planning Criteria Guide as a reference, programming translates the concept of operations into a line-by-line space program document. Because the DoD Space Planning Criteria Guide does not always reflect the latest EBD science, it may be necessary to form a multidisciplinary community of practice to fully address emerging EBD science to mitigate the risk of EBD innovation. The space program document (i.e., Program for Design, or PFD) that is ultimately produced consists of the elements identified below, with full use of the comments section to provide key planning assumption information to the Architect-Engineer. - DoD room code - Room name - Size and number of each type of room - Total NSF - Reference to DoD Space Criteria - Comments Noblis has created, for the planning work in the NCA, a web-based PFD tool which can be used to track the changes in the program for design. Each PFD was vetted with the relevant user groups during the planning and programming phase.
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Programming EBD Checklist How well does the DoD Space Criteria Guide support the desired EBD features? Use the comments section to provide design guidance that links a room to key EBD CONOPS elements.
Design
Design Definition Design involves the creation of drawing plans using a multidisciplinary approach for the builders to use in construction. Designs are submitted in an iterative fashion, which until recently included the following design submittals (S): S1 - Block layout (inpatient, ancillary, outpatient, parking) on the site S2 - Department adjacencies S3 - Room adjacencies S4 - Equipment and furniture layouts within rooms S5-S6 the guts - communication, HVAC, mechanical, lighting, etc. Intense efforts are underway to transform design and construction practices from a linear, sequential approach to an integrated design-build process, most typically used in the civilian sector, which will reduce the number of designs submitted. Design EBD Activities Checklist At what point in the design plan would you expect to find each of the desired EBD features? During the appropriate design review, ensure that all of the EBD features have been captured. Does the design support the desired EBD future concepts from all perspectives: patient, family and visitors, the community, staff, material movement, equipment use, seamless integration with technology and the digital infrastructure? Has Failure Modes and Effects Analysis been conducted to ensure that the design does not contribute to risks and failure?
Construction
Construction Definition Construction represents the actual building of the facility, including placement of some of the built-in equipment. Historically, construction began after the design was completed. Today, construction may begin as design is being completed, to shorten the time between the decision to build and facility occupancy. Construction EBD Activities Checklist Are the materials Green Guide approved? Are the materials supportive of the desired EBD features? Have precautions been taken to minimize the impact (noise, particles, etc.) of construction on adjacent or nearby facilities and their occupants?
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Sustainment
Sustainment Definition Sustainment begins with the post-occupancy EBD evaluations and represents the routine maintenance and repair activities necessary to keep the building in good working order over the life of the building. Sustainment EBD Activities Checklist Have the post-occupancy evaluations of EBD features on patient, staff and resource outcomes been completed at the appropriate times (e.g., at 6, 12, and/or 24 months)? Have the lessons learned been documented and shared broadly? Are there opportunities to insert EBD features with routine maintenance and repair activities, such as: High performance sound-absorbing ceiling tiles? Rubber and carpeted floors where appropriate? Glass that reduces glare? Furnishing replacement and reconfiguration for waiting areas/lounges to provide a residential look? Selection of materials (wall coverings, furniture, etc.) with cleanability and low emissions as key considerations? Improved signage? Housekeeping practices that include frequent cleaning of high-contact surfaces? Well maintained and operated ventilation and water supply systems? Using green cleaning materials?
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In summary, EBD activities can occur at every phase of the Facility Life Cycle Management and Performance Model for every type of facility project: regular facility maintenance, life and safety upgrades, renovation and/or renewal projects, and medical MILCON projects.
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Recommendations
Recommendations
Patient controls of light, glare and temperature Improved lighting levels in areas where medications are prepared and dispensed and in procedure areas Windows in staff break rooms Convenient food facilities for patients and families Decentralized inpatient nursing support Regular maintenance, cleaning and inspection of water systems (or use of looped water systems to minimize maintenance requirements) Proper water treatment practices Avoiding decorative water fountains in high-risk patient care areas Cleaning high-contact surfaces frequently Sinks and hand-washing dispensers Ensuring that HVAC systems are well maintained and operated Materials and furnishings that do not emit toxins Isolate construction and renovation areas from patient-care areas Provide secure access to nature Provide positive distractions (music, appropriate art, etc.) Provide multiple spiritual spaces and haven areas Use softer floor materials like carpet and rubber as appropriate Ergonomically evaluate work areas Decentralize staff support spaces (e.g., supplies and charting areas) Provide flexible spaces for interactive team work Consider using brass or copper door handles Optimize unit adjacencies with Care Centers, (e.g., Cancer Care, Musculoskeletal Care). As was demonstrated in the previous section, EBD activities exist in every phase of the Facility Life Cycle Management and Performance Model, not just the design phase, and are provided as a checklist for use by the facilities community.
Next Steps
Much MHS work is needed to institutionalize EBD research and findings. Successful institutionalization includes all of the following activities: Engage Senior Leaders. Senior leaders must be engaged and EBD champions identified to provide the transformational leadership essential to EBD success. Partner with Clinical and Administrative Peers. The built environment is one of many tools used to provide quality patient care and a positive workplace. All EBD work should be accomplished in deliberate partnership with the clinicians and administrators who can then lead the necessary clinical and business-process engineering necessary to maximize these expensive facility investments. Include Patients and Their Families in Health Facility Planning Activities. Our customers must be involved in all aspects of their care.
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Recommendations
Review and Update Policy. Do the current DoD facility policies and guidelines include all of the recommended EBD features and responses? A standard Return On Investment analysis process for EBD projects should be drafted and completed with the resource managers. Review and Restructure Health Facility Organizations. Are the Service (e.g., Army Health Facility Planning Agency, MEDCOM ACS for Installations and Environment) and OSD/HA-TMA facility organizations structured to incorporate and monitor EBD activities across the spectrum of facility responsibilitiesfrom Medical MILCON projects to Life and Safety upgradesand to partner with key clinical and administrative policy peers? How will the organizations support inquiries for known and emerging EBD information? Develop Processes to Harvest Emerging EBD Findings. As EBD research efforts continue to grow in both the public and private sectors, there is a need to establish processes to harvest and share emerging EBD findings. Many health facility staff attend national meetings and conferences, but seem to have difficulty translating what is learned into a practical resource that informs their work. Evaluate EBD Cost-Estimating Guidance. Many EBD features and responses are consequent to good design with existing criteria. Current EBD costing-estimate guidance should be evaluated, with particular attention paid to grossing factors associated with EBD facilities. Current preliminary results of a study at Clemson & Texas A&M shows contemporary grossing factors do not differ significantly from those of some time ago.118 Perform Return on Investment Analysis. For many recommended EBD features, there will be an associated capital cost. While the EBD literature suggests that return on investment is possible within relatively short periods of time for many of these features, so many factors influence the determination of both cost and potential savings that it is difficult to make an overarching statement that incorporation of EBD features will definitely save the MHS money. For each building project, the planning and programming teams should take the time to perform ROI analyses of the features that they have determined to be most desirable for their project. This will necessitate the development of agreed upon outcome measures, defined in a way to afford the greatest ability to compare findings with those in the civilian sector and across the MHS. Disseminate EBD Information. How will each Service and OSD/HA-TMA disseminate EBD information? What basic EBD education experiences are needed? How can the training be accomplished using existing forums as well as other means (e.g., web symposium) to provide the widest dissemination of information? Presentations should be provided at major clinical and administrative forums, not just those forums that traditionally support the facilities community. Review Outcome Metrics Definitions and Methodology. Are the outcome metrics used to measure success commensurate with those used in the civilian sector? Coordination with the DoD Metrics Standardization Board may be necessary.
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Recommendations
Conduct EBD Research in the Ambulatory and Dental Environments. Almost all of the EBD research has occurred in the inpatient environment. Many EBD features found to improve patient, staff and resource outcomes in the inpatient environment would seem to be transferable to the outpatient and dental environments, which represent the largest portion of the DoD facilities portfolio. Become a Pebble Project. The MHS has a unique opportunity to become an active member in the national community to further EBD by becoming a member of the Center for Health Designs Pebble Project (see page 14 for more information about the project). At a minimum, the New Fort Belvoir Community Hospital, the New Walter Reed National Military Medical Center, and the New San Antonio Military Medical Center should be Pebble Projects. Refine the Post-Occupancy Evaluation Process. Post-Occupancy evaluations now need to include an analysis of patient, staff and resource outcomes impacted by the facility project. Redefine the Life Cycle Cost Analysis. Current healthcare facility life cycle cost analysis is based on a traditional, nonhealthcare facility approach and ignores the heart of our business: providing patientcentered and family-focused care. The life cycle cost analysis should be broadened to include the financial impacts associated with improving patient, staff and resource outcomes compared to the facility investments proven to improve those outcomes. Publish MHS EBD Experiences and Lessons Learned. The MHS frequently leads the way in innovation, but rarely or inadequately shares those innovations and outcomes in a formal way. Formalize Current EBD Working Groups. The Epidaurus Project and the EBD Working Group should be formalized under TMA as an Integrated Process Team (IPT) to facilitate many of the next steps described here. Conclusion With a $6 billion portfolio of new healthcare facilities and projects planned over the next five years119, the MHS finds itself with a once-in-a-lifetime opportunity to transform the healthcare infrastructure to improve patient, staff and resource outcomes and to contribute to the body of EBD science. This report provides a snapshot of the current EBD evidence applied to MHS EBD goals and principles that can be used to transform and educate the MHS healthcare community. Although the current AIA and DoD planning criteria embrace many of the recommended EBD features, the reader is encouraged to stay abreast of the latest EBD information through the Center for Health Design and is reminded that maximizing EBD investments depends on transformational leadership and clinical and business process reengineering. Employing recommended EBD features and responses across the Facility Life Cycle provides a singular opportunity to create the next generation of MHS healthcare facilities that can support the outcomes our warriors and their families deserve.
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ATTACHMENTS
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Attachment 1
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Attachment 1
The Spine Hospital of South Texas The Spine Hospital of South Texas is a fully licensed, acute care hospital, specializing in orthopedics and diagnostic imaging. It was built in 2002 and has approximately 45,000 square feet of space, 6 operating theaters, 2 treatment rooms and 30 patient rooms. The hospital is a for-profit, privately-owned, physician partnership attached to a private medial office building (where the majority of ambulatory visits and minor procedures are performed). The physician owners and their partners designed and built the facility with a focus on efficiency, patient care and safety, and patient satisfaction. The single floor layout of this small hospital provides staff efficiencies in monitoring the flow of patients (e.g., dual coverage of a small emergency department and inpatient units with low patient census on weekends) with efficient staffing ratios. Also, design elements for the productive spaces such as the operating rooms include separate circulation of patients versus staff and equipment. This facility design results in maximizing the use of space while enhancing patient safety and satisfaction. The Hospital has consistently received high patient satisfaction scores and was named Best in Customer Service (July 2004) by National Surgical Hospitals. The staff are welltrained to be sensitive to the patient needs, including family-centered care. The focus on a warm and caring environment is reinforced by the design of hotel-like amenities, including larger patient rooms, large tiled showers in private toilet rooms, carpeted hallways, and warm interior colors and design features.
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Attachment 2
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Attachment 2
Soiled material collection Linen supplies Electronic medical record access - We envision a wireless environment. Room Service Concept - Patients can order what they want to eat when they want it. Staff work space - Hoteling space for clinicians and administration staff
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Attachment 3
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Attachment 3
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Attachment 4
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Attachment 4
Goal 1-4: Provide Adequate and Appropriate Light Exposure Impact of Different Lighting Conditions on Staff Work Performance Providing quality healthcare involves multiple complex tasks from medication preparation and administration, conducting invasive and non-invasive procedures, and documenting care. Several studies summarized in Josephs 2006 article on light showed that exposure to intermittent bright light during the night shift is effective in adapting circadian rhythms of night-shift workers.v Additional research is needed to understand the ideal light level for a variety of error-prone tasks by workers of varying ages. Impact of Natural Light versus Artificial Light on Staff Mood and Performance Some studies have shown that staff exposure to natural light has a positive impact on their work experience. More work is needed to understand the importance of natural light to staff and specifically any impacts on staff performance, especially as the healthcare workforce ages. Goal 1-5: Support Optimal Patient Nutrition Assess Current MHS Food Service Facilities and Family Involvement with Nutrition A nutrition support question might be included on the MHS patient satisfaction survey as a first step to understanding the current status of this issue. Simultaneously, a community of practice involving patients, their family members, nutritionists, nursing staff and providers could be formed to: Explore the degree to which a problem exists, particularly for war-wounded patients who experience lengthy hospitalizations far from home. Identify potential improvements that require a facility solution and the associated costs of such solutions. Identify patient outcome improvements and quantify these. Identify family nutrition support requirements. Conduct a return on investment (ROI) analysis to request approval and funding for additional building features. Goal 1-6: Improve Patient Sleep and Rest Patient Satisfaction with Sleep and Rest Current patient satisfaction with the quality of rest and sleep in MHS facilities is unknown. Inpatient satisfaction surveys could be modified to include a question about this important patient outcome. Depending on the results, a community of practice may need to be formed to address identified problems and to consider facility solutions and clinical practice modifications. Goal 1-7: Decrease Exposure to Harmful Chemicals Green Guide Adherence Across Each Phase of the Facility Life Cycle Performance and Management Model The degree to which the Green Guide recommendations are adhered to at each phase of the Facility Life Cycle Management and Performance Model, but particularly in the sustainment phase is not known.
v
Joseph, A. August 2006. Impacts of Light on Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org,
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Attachment 4
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Attachment 4
bacteria (including E. coli) has been studied in the laboratory. However, only limited studies have been done in the healthcare environment. The MHS could study the effect of using these materials for high-contact surfaces in areas where patients are particularly vulnerable to infection, such as the ICU or ER. Goal 2-3: Prevent Waterborne Infections (None.) Goal 2-4: Reduce Medication Errors Optimal Lighting Requirements for Medication Administration Activities More research is needed to understand the optimal lighting requirements for supporting medication administration and staff performance. Impact of Family Presence on Medication Errors The impact of family member presence on medication errors for those patients cared for in single-bed rooms with family support space versus those patients cared for in multibed rooms without family support space is worth studying. Impact of Decentralized Nursing Support on Medication Errors Decentralized nursing support is planned for the New WRNMMC and Fort Belvoir Community hospitals, to include automated medication dispensing for routine and scheduled medications. It is not known what impact this will have on medication error rates. Goal 2-5: Prevent Patient Falls Reduce Patient Falls in MHS Hospitals Patient falls are also a problem in MHS hospitals. With the Patient Safety and Performance Improvement communities, the impact of recommended EBD features in new MHS hospitals combined with other fall prevention initiatives should be studied with regard to reducing the number of patient falls. Impact of Decentralized Support on Patient Falls The impact of decentralized support on the incidence of patient falls in MHS hospitals is not known. Perhaps a present unit could be configured with the decentralized support described and then evaluated with regard to patient falls and other key safety and quality patient outcomes as part of the transition planning activities for the NCA projects. An ICU unit under renovation in the current WRAMC will include decentralized support and could be used for this study. Goal 2-6: Reduce Noise Stress and Improve Speech Intelligibility Evaluate the Practice of Replacing Existing Ceiling Tile with High-Performance Sound Absorbing Acoustical Ceiling Tile and Its Impact on Patient Outcomes Select any current inpatient unit with old ceiling tile and replace it with the recommended tile and evaluate patient rest, sleep, satisfaction, perception of pain and need for medication before and after replacement.
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Attachment 4
EBD Principle 3: Enhance Care of the Whole Person (Contact with Nature & Positive Distractions)
Goal 3-1: Decrease Patient and Family Stress MHS Patient Satisfaction with Access to Nature Positive Distractions Identify current patient satisfaction with regard to access to nature and positive distractions and identify those elements that positively and negatively contribute to the care of the whole person.
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Attachment 4
at WRAMC and NNMC and could be studied with regard to team effectiveness and patient satisfaction. Smaller Unit Size to Foster Interaction DoD Space Criteria provides specific recommendations for the number of beds by specific unit type. At the New WRNMMC, a number of the planned medical surgical units are larger than the DoD recommendation not to exceed 36 beds because of funding and physical constraints. A pod design concept with decentralized support was planned to mitigate some of the challenges inherent in large units. Likewise, many civilian hospitals also are building large units (40 beds) with pod support. Understanding and applying civilian lessons learned about team effectiveness with regard to this approach is an important transition planning undertaking. Goal 4-4: Eliminate Noisy, Chaotic Environments NCA MTF Noise and Impact on Staff Stress, Performance and Retention. There is little baseline information about the impacts of existing NCA stressful environments, like the ICUs, on staff. Replicating Topf and Dillons study may provide important insights for the new facilities, particularly with regard to staff training and developing policies and guidelines.
EBD Principle 5: Design for Maximum Standardization, Future Flexibility and Growth
Goal 5-1: Reduce Room Transfers WRAMC ICU Renovation A renovation project is planned for the existing WRAMC that will incorporate may of the EBD features described, including acuity adaptable rooms. Patient and staff outcomes should be studied as part of the transition planning for occupying the New WRNMMC and Fort Belvoir Community Hospital. Goal 5-2: Facilitate Care Coordination and Patient Service Examine Existing Care Centers for Positive Physical Attributes A number of care centers exist in NCA facilities today, such as Breast Cancer Care. A qualitative analysis about the positive and negative physical aspects of these existing centers that engages both staff and patients may provide important information to consider in design and transition planning. Examine the Use of Flexible Public Spaces to Support Multiple Missions, Some of Which May Be Military Unique. There has been no systematic review of how the facility design supports multiple care mission requirements, such as MASCALs and the associated patient, staff and resource outcomes, as a consequence. Table top exercises using recent contingency events such as the 9-11 strike on the Pentagon should be simulated with the planned designs for both NCA facilities.
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End Notes
END NOTES
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End Notes
END NOTES
1
"The Four Levels of Evidence-Based Design Practice. D. Kirk Hamilton, Healthcare Design, November 2003. From the abstract of Crossing the Quality Chasm, March 2001, by the Institute of Medicine (part of the National Academy of Sciences). Building a Health Care System That Works: Here, There and Everywhere. Institute for Healthcare Improvement, December 2006. 2006 Guidelines for Design and Construction of Health Care Facilities. 2006. The Facility Guidelines Institute, the American Institute of Architects Academy of Architecture for Health. Chapter 1.2: Environment of Care, pp 15-20. Planetree website. http://www.planetree.org/about/welcome.htm Suggested by Mr. Don McKahan, AIA, FACHA (Health Facility Planner); (dmckahan@mckahan.com) and Mr. Joseph Strauss, AIA, Architect at Noblis. Suggested by Dr. Anjali Joseph, Director of Research, The Center for Health Design. Military Health System. Quadrennial Defense Review: Roadmap for Medical Transformation. 3 April 2006. Ulrich, R., Zimring, C., Quan, W., and Joseph, A. 2004. The Role of the Physical Environment in the Hospital of the 21st Century. Concord, CA: The Center for Health Design, web site, www.healthdesign.org, in the Research Reports section. Ulrich, R., and Joseph, A. November 2005. Scorecards for Evidence-Based Design. Concord, CA: The Center for Health Design, web site: www.healthdesign.org Joseph, A. 2007. Personal communication 3 May 2007. Nelson, C, West, T., Goodman, C. 2005. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: Agency for Healthcare Research and Quality, Publication Number 05-0106-EF. Marberry, S.O. Ed. 2006. Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press Schroder, K. 2006 Designing for Quality: Potential for Facility Design to Elevate Patient Outcomes. 2007Innovations Center: Health Care Advisory Board, p.11 Joseph, A and Ulrich, R.S. January 2007. Sound Control for Improved Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Joseph, A. 2006. The Impact of the Environment on Infection in Healthcare Facilities. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Joseph, A. August 2006. Impacts of Light on Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Joseph, A. 2006. The Role of the Physical and Social Environment in Promoting Health, Safety and Effectiveness in the Healthcare Workplace. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section. Zimring, C. 2007. Personal communication with the author of the soon-to-be published article. Roberts, G. and Guenther, R. 2006. In Chapter 5 Environmentally Responsible Hospitals. in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, pp. 81-107.
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End Notes
See www.gghc.org ; Green Guide for Health Care version 2.1. and www.usgbc.org; Leadership in Energy and Environmental Design (LEED) Green Building Rating System. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environments Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 53. Uchino, B.N. and Garvey, T.S. 1997. The Availability of Social Support Reduces Cardiovascular Reactivity to Acute Psychological Stress. Journal of Behavioral Medicine 20(1):15-27. Holahan, C.J. 1972. Seating Patterns and Patient Behavior in an Experimental Dayroom. Journal of Abnormal Psychology 80 (2): 115-124. Melin, L., and Gotestam, K.G. 1981. The effects of Rearranging Ward Routines on Communication and Eating Behaviors of Psychogeriatric Patients. Journal of Applied Behavior Analysis 14 (1): 47-51. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environments Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 54. Sallstrom, C., Sandman, P.O. and Norber, A. 1987. Relatives Experience of the Terminal Care of Long Term Geriatric Patients in Open Plan Rooms. Scandinavian Journal of Caring Science 1 (4): 133-40 Personal communication with Sheila Bosch, Georgia Tech University, 27 June 2007. Landro, L. 12 July 2007. ICUs New Message: Welcome Families." The Wall Street Journal, Section A1 and 12. Zimring, C. 1990. The Costs of Confusion: Non-Monetary and Monetary Costs of the Emory University Hospital Wayfinding System. Atlanta: Georgia Institute of Technology Presentation at the MHS TRICARE Conference, January 2007. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environments Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 42-45. Malkin. J. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 113-114. Ibid. Boodman, S. G. A Silent Epidemic. The Washington Post, February 20, 2007, F1-F2. Barlas, D., Sama, A.E., Ward, M.F., and Lesser, M.L. (2001). Comparison of the Auditory and Visual Privacy of Emergency Treatment Areas with Curtains Versus Those with Solid Walls. Annals of Emergency Medicine 38 (2), 135-139. Joseph, A and Ulrich, R.S. January 2007. Sound Control for Improved Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, pp 6-9. Ibid, p7. Joseph, A. August 2006. Impacts of Light on Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.4-8. Ibid, page 5. Walch, J. M., Rabin, B. S., Day, R., Williams, J. N., Choi, K. and Kang, J. D. (2005) The Effect of Sunlight on Postoperative Analgesic Medication Usage: A Prospective Study of Spinal Injury Patients. Psychosomatic Medicine 67(10, 156-163. Joseph, A. August 2006. Impacts of Light on Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.3-4.
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Buchanan, T.L., Barker, K.N., Gibson, J. T., Jiang, B.C., and Pearson, R.E. (1991). Illumination and Errors in Dispensing. American Journal of Hospital Pharmacy 48 (10), 2137-2145. Joseph, A and Ulrich, R.S. January 2007. Sound Control for Improved Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p. 5. www.gghc.org; Green Guide for Health Care version 2.1. Nycz-Xonner, J. 2007 Scrub In: Infections Take Fiscal, Human Toll, Force Hospitals to Clean Up. Washington Business Journal, March 26, 2007, http://washington.bizjournals.com/washington/stories/2007/03/26/focus1.html Pennsylvania Health Care Cost Containment Council. 2006. Hospital Acquired Infections in Pennsylvania. www.phc4.org , p.1. Spinner, J. 2007. Resilient Infections Worry Military Doctors. The Washington Post, 5 May 2007, pp. B1-2. Joseph, A. The Impact of the Environment on Infection in Healthcare Facilities. . The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.1-6. Sherertz, R. A., Belani, A., Dramer, B.S., Elfenbein, G. J., Weiner, R. S., Sullivan, M. L. et al. (1987) Impact of Air Filtration on Nosocomial Aspergillus Infections: Unique Risk of Bone Marrow Transplant Recipients. American Journal of Medicine, 83 (4), 709-718. Hahn, T, Cummings, K. M., Kichalek, A. M., Lipman, B. J., Segal, B. H., McCarthy, P. L. 2002. Efficacy of High-Efficiency Particulate Air Filtration in Preventing Aspergillosis in Immunocompromised Patients with Hematologic Malignancies. Infection Control and Hospital Epidemiology 23 (9), 525-531. Passweg, J. R., Rowlings, P. A., Atkinson, K. A., Barrett, A. J., Gale, R. P., Gratwhohl, A., et al. 1998. Influence of Protective Isolation on Outcome of Allogeneic Bone Marrow Transplantation for Leukemia. Bone Marrow Transplant 21 (12), 1231-1238. Noskin, et al. (2001) Engineering Infection Control through Facility Design. Emerging Infectious Diseases, 7 (2), p ____. Menzies, D., Popa, J., Hanley, J.A., Rand, T., and Milton, D. K. 2003. Effect of Ultraviolet Germicidal Lights Installed in Office Ventilation Systems on Workers Health and Wellbeing: Double-Blind Multiple Crossover Trial. 362 November 29, 2003, pp. 1785-1790. Escombe, A. R., Oeser, C. C., Gilman, R. H., Naavincopa, M., Pan, E. W., Martinez, C., et al. 2007 Natural Ventilation for the Prevention of Airborne Contagion. Public Library Science of Medicine, found at http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040068 Joseph, A. The Impact of the Environment on Infection in Healthcare Facilities. . The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.5. Ibid, p. 6. Collins, B.J. 1988 The Hospital Environment: How Clean Should a Hospital Be? Journal of Hospital Infection Control, 17 (6), 330-339. Oligodynamic effect reference in Wikipedia.com. Original article by Ngeli: v. Ngeli K.W. 1893. ber oligodynamische Erscheinungen in lebenden Zellen. Neue Denkschr. Allgemein. Schweiz. Gesellsch. Ges. Naturweiss. Bd XXXIII Abt 1. Michels, H.T.; Wilks, S.A.; Noyce, J.O.; and Keevil, C.W. 2005. Copper Alloys for Human Infectious Disease Control. p. 1-11. Download at: www.cda.org.uk/antimicrobial/downloads/infectious_disease.pdf Joseph, A. The Impact of the Environment on Infection in Healthcare Facilities. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.11-12.
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Rogers, J. 2006. The Debate over Decorative Fountains in Healthcare Environments: How Great is the Infection Control Risk? Research Design Connections, Winter 1-3. Ulrich, R., Zimring, C., Quan, W., and Joseph, A. 2004. The Role of the Physical Environment in the Hospital of the 21st Century. Concord, CA: The Center for Health Design, web site, www.healthdesign.org, in the Research Reports section, p.12 Institute of Medicine. 2007. Preventing Medication Errors: Quality Chasm Series. Washington D.C.: National Academies Press, Appendix D. p.413. Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., Roth, E. A., and Shekelle, P. G. 2004. Interventions for the Prevention of Falls in Older Adults: Systematic Review and Meta-Analysis of Randomised Clinical Trials. British Medical Journal. 328 (7441): 680. Brandis, S. 1999. A Collaborative Occupational Therapy and Nursing Approach to Falls Prevention in Hospital Patients. Journal of Quality in Clinical Practice. 19 (4), 215-21. Walker, Dalton. Hospital in Bronx Shows How to Turn Volume Down. July 6, 2007. The New York Times. Busch-Vishnia, I., West, J., Barnhill, C., Hunter, T., Orellana, D., and Chivukula, R. 2005 Noise Levels in Johns Hopkins Hospital. Journal of the Acoustical Society of America. 118(6):3629:45. Zimring, C. 2007. Using Evidence-Based Design to Improve Quality, Safety and the Bottom Line. Presented at the TRICARE Conference, Washington D.C., 29 January 2007. Fife, d., and Rappaport, E. 1976. Noise and Hospital Stay. American Journal of Public Health. 66 (7): 68081. Hagerman, IL, Rasmanis, G., Blomkvist, R. S. Ulrich, C., Eriksen, A, and Theorell, T. 2005. Influence of Coronary Intensive Care Acoustics on the Quality of Care and Physiological States of patients. International Journal of Cardiology 98:267-270. Busch-Vishnia, I., West, J., Barnhill, C., Hunter, T., Orellana, D., and Chivukula, R. 2005 Noise Levels in Johns Hopkins Hospital. Journal of the Acoustical Society of America. 118(6):3629:45. Topf, M. and Dillon, E. 1988. Noise-induced Stress as a Predictor of Burnout in Critical Care Nurses. Heart Lung 17 (5):567-74. Joseph, A and Ulrich, R.S. January 2007. Sound Control for Improved Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.3-4. Ibid, p. 4-5. Ulrich, R., Zimring, C., Quan, W., and Joseph, A. 2004. The Role of the Physical Environment in the Hospital of the 21st Century. Concord, CA: The Center for Health Design, web site, www.healthdesign.org, in the Research Reports section. Diette, G.B., Nechzin, N., Haponik, E., Devrotes, A., and Rubin, H.R. 2003. Distraction Therapy with Nature Sights and Sounds Reduces Pain During Flexible Bronchoscopy: A Complementary Approach to Routine Analgesia. Chest 123(3): 941-48. Ulrich, R.S. 1984. View Through a Window May Influence Recovery from Surgery. Science 224(4647): 420-21. Malkin. J. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 117. Ulrich, R.S., Zimring, C., Quan, X., and Joseph, A 2006 in Chapter 3, The Environments Impact on Stress in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 49.
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Malkin. J. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 117. Heerwagen, J. 1990. The Psychological Aspects of Windows and Window Design. In Proceedings of the 21st Annual Conference of the Environmental Design Research Association, edited by K.H. Anthony, J. Choi, and B. Orland. Edmond, OK: Environmental Design Research Association. Chlan, L.L. 2000. Music Therapy as a Nursing Intervention for Patient Supported by Mechanical Ventilation. American Association of Critical Care Nurses. 11:128-38. Lee, O., Chung, Y., Chan, M.F. and Chan, W.M. 2005. Music and its Effect on the Physiological Responses and Anxiety Level of Patients Receiving Mechanical Ventilation: A Pilot Study. Journal of Clinical Nursing 14:609-20. Chlan, L.L. 2000. Music Therapy as a Nursing Intervention for Patient Supported by Mechanical Ventilation. American Association of Critical Care Nurses. 11:128-38. Ibid Chang, S., and Chen, C. 2005. Effects of Music Therapy on Womens Physiologic Measures, Anxiety and Satisfaction During Cesarean Delivery. Research in Nursing & Health 28 (6): 453-61. Lai, H., Chen, C., Peng, T., Chang, F., Hsieh, M, Huang, H., and Change, S. 2006. Randomized Controlled Trial of Music during Kangaroo Care on Maternal State Anxiety and Preterm Infants Responses. International Journal of Nursing Studies 43:139-46. McCaffrey, R. and Locsin, R. 2004. The Effect of Music Listening on Acute Confusion and Delirium in Elders Undergoing Elective Hip and Knee Surgery. International Journal of Older People Nursing 13(6b):91-96. Fragala, G. and Bailey, L. 2003. Addressing Occupations Strains and Sprains: Musculoskeletal Injuries in Hospitals. AAOHN Journal 51 (6): 252-259. Nelson, A. and Baptiste, A.S. 2006. Update on Evidence-based Practices for Safe Patient Handling and Movement. Orthopedic Nursing 25(6), 367-368. American Nurses Association. 2002. Preventing Back Injuries: Safe Patient Handling and Movement. Silver Spring: MD Nelson, A. and Baptiste, A. Evidence-based Practices for Safe Patient Handling and Movement. Online Journal of Issues in Nursing. 9 (3), Manuscript 3 at www.nursingworld.org/ojin/topic25/tpc25_3.htm. Joseph, A. and Fritz, L. 2006. Ceiling Lifts Reduce Patient-Handling Injuries. Healthcare Design, 6:10-13. Ibid. Engst, C., Chhokar, R., Miller, A., Tate, RB and Yassi, A. 2005. Effectiveness of Overhead Lifting Devices in Reducing the Risk of Injury to Care Staff in Extended Care Facilities. Ergonomics 48 (2): 187-99. Chhokar, R. Engst, C., Miller, A., Robinson, D., Tate, RB, and Yassi, A. 2005. The Three Year Economic Benefits of a Ceiling Lift Intervention Aimed to Reduce Healthcare Worker Injuries. Applied Ergonomics, 36 (2), 223-9. 110th Congress, 1st Session. HR 378 Nurse and Patient Safety & Protection Act of 2007. Washington D.C. 10 January 2007. Redfern, M and Cham, R. 2000. The Influence of Flooring on Standing Comfort and Fatigue. American Industrial Hygiene Association Journal, 61:700-708. Joseph, A. 2006. The Role of the Physical and Social Environment in Promoting Health, Safety and Effectiveness in the Healthcare Workplace. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p.3-4.
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Burgio, L., Engle, B., Hawkins, A., McCormick, K., and Scheve, A. 1990. A Descriptive Analysis of Nursing Staff Behaviors in a Teaching Nursing Home: Differences Among NAs, LPNs and RNs. The Gerontologist 30(1): pp, 107-112. Shepley, M.M and Davies, K. 2003. Nursing Unit Configuration and Its Relationship to noise and Nurse Walking Behavior: An AIDS/IHI Unit Case Study. AIA Academy Journal, http://www.aia.org/aah_a_jrnl_0401_article4. Gardner, Dave. A technological finger on the pulse of a busy ER. June 29, 2007. Northeast Pennsylvania Business Journal. Joseph, A and Ulrich, R.S. January 2007. Sound Control for Improved Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section, p. 8. Joseph, A. August 2006. Impacts of Light on Outcomes in Healthcare Settings. The Center for Health Design web site, www.healthdesign.org, in the Research Reports section Ibid, p. 9. Ibid, p. 5. Morrison, W.E., Haas, E.C., Shaffner, D.H., Garrett, E.H, and Fackler, J.C. (2003) Noise Stress and Annoyance in a Pediatric Intensive Care Unit. Critical Care Medicine 31(1): 113-119 Topf, M. and Dillon, E. 1988. Noise-induced Stress as a Predictor of Burnout in Critical Care Nurses. Heart Lung 17 (5):567-74. Houston, A., Mitchell, J., Borgani, M., Bumazhny, A. et al. 22 May 2007 Modern Facility Design and Its Impact on Operational and Capital Investments. Fitch Ratings, at www.fitchratings.com, p. 2. DeFrances, C.J., Hall, M.J., and Podgornik, M.N. (2005) 2003 National Hospital Discharge Survey: Advance Data for Vital and Health Statistics. Hyattsville, MD: Us Department of Health and Human Services, CDC, National Center for Health Statistics. Hendrich, A., Fay, J., and Sorrells, A. 2004 Effects of Acuity-Adaptable Rooms on Flow of Patients and Delivery of Care. American Journal of Critical Care 13(1): 35-45. Schroder, K. 2006 Designing for Quality: Potential for Facility Design to Elevate Patient Outcomes. 2007Innovations Center: Health Care Advisory Board, p.11. Mohr, J.J., Batalden, P., Barack, P. 2004. Integrating Patient Safety into the Clinical Microcosm. Quality and Safety in Health Care; 13 (Supply II): pp. 1134-38. Doe 10.1136/qshc.2003.009571. Reiling, J. ___ Designing a Safe Hospital. Center for the Study of Healthcare Management, Department of Healthcare Management, Carlson School of Management: University of Minnesota, Publication 1 Series. Calhoon, B. 2007. NCA Patient Focus Group Recommendations, Personal conversation, 13 February 2007. Transforming Strategy into Action, a presentation at the Military Health System (MHS) 2007 Annual Conference, held in Washington, DC, January 29-February 1, 2007. Sadler, B., Hamilton, K., Parker, D., and Berry, L. in Chapter 6 Designing a Better Environment in Improving Healthcare with Better Building Design, Marberry, S.O. Ed. Chicago: Health Administration Press, p. 125-143. Hamilton, K. Personal e-mail communication on 4 May 2007. The number that has been floated over the past two years is $6 Billion over the next 5 years for BRACrelated Medical MILCON investments. (This figure may also include some of the Armys transformation initiatives). Typically, the MHS spends on the order of $300M per year for Medical MILCON, and approximately $1B+ per year on all non-MILCON, Operations and Maintenance (O&M) expenditures.
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