The hospital (and community)

as a healing environment

Accelerate the co-production of health and health care with patients, families, communities and…

architects, and designers

Paul Barach, MD, MPH July 25, 2014

American College of Healthcare Conference

I Have a Dream: What’s Yours? •  All health care environments should be healing

environments •  They should feel more like home •  They should help make getting better easier, not

harder. •  They should help restore joy in work. •  They should help people get what they really,

really want – to have more choice and control, and less anxiety and confusion.

•  Whether a patient is in our care for an hour, a day, a week, or a year, they deserve an optimal healing environment

After Blair Sadler

Politics and medicine

   “Medicine  is  a  social  science  and  medicine  is  nothing  but  poli4cs  on  a  grand  scale”    

 Rudolf  Virchow,  (1821-­‐1902)  Prussian  physician,  one  of  the  originators  of  the  

cell  theory,  worked  out  the  mechanism  of  pulmonary  thromboembolism,  wri4ng  

about  the  1848  typhus  epidemic  in  Upper  Silesia  

HEALTH SYSTEMS COMPARATIVE DATA

Concurrent Revolutions •  Harm prevention •  Patient centeredness--salutogenesis •  Increasing Patient Expectations •  Paying for Value instead of Volume •  Reducing variations •  Value (Quality/cost) Safety, reliability •  Transparency of Outcomes and Scores •  Environmental Sustainability is Now Mainstream •  Discouraged, Unhappy Workforce, Vendors and …

Architects

Our Challenge: Key System Drivers

Health

Social Economic

Population Health/Patient

Politics, regulations and agencies

6

THREE CONCURRENT REVOLUTIONS

Health care consumes 18% of US energy annually

Slide: 8 © 2009 Perkins+Will

PATIENT CENTERED

TIMELY EFFICIENT

EFFECTIVE

SAFE

EQUITABLE

QUALITY

Components of Quality

QUALITY

FURNISHINGS

LIGHT MATERIALS

WAYFIN

DIN

G

AROMA

ART

The Translational Initiatives

Public Health Sciences

Drug Development /

Cancer

Biomedical Engineering

Device Development

Personalized Medicine

Core Resources And

Competencies

Popula'on  Health  Management  System of Care

Wellness Model

IGNAZ  SEMMELWEIS  –  USE  OF  CHLORINATED  LIME  HAND  WASHING  FOR  PREVENTION  OF  PUERPERAL  FEVER  (THE  MIDWIVES’  WARD  LOWER  THAN  DOCTORS’)  

 

Semmelweis – the mortality rate in April 1847 was 18%; after hand washing was instituted in mid-May, the rate in July was 1%

DR  IGNAZ  SEMMELWEIS’S  FATE      

     Semmelweis  was  outraged  by  the  indifference  of  the  medical  profession  to  pa4ent  suffering  and  death  ...  His  contemporaries,  including  his  wife,  believed  he  was  losing  his  mind,  and  in  1865  he  was  commiPed  to  an  asylum..  he  died  there  of    sep4caemia  only  14  days  later,  possibly  from  the  result  of  being  severely  beaten  by  guards    

HH: hand hygiene. OT: operating theatre. NSG: non-sterile gloves. SG: sterile gloves Annelot C Krediet, et al. Hygiene Practices in the Operating Theatre: An Observational Study., BJA, 2011

Normalized Deviance •  By a deviant organizational behavior, we refer to “an

event, activity or circumstance, occurring in and/or produced by a formal organization, that deviates from both formal design goals and normative standards or expectations, either in the fact of its occurrence or in its consequences.”

•  Once a community normalizes a deviant organizational practice, it is no longer viewed as an aberrant act that elicits an exceptional response; instead, it becomes a routine activity that is commonly anticipated and frequently used.

Diane Vaughan, 1999: 273. ; Barach, Phelps 2013

How does it start? •  The normalization literature distinguishes

between factors that lead to the genesis of organizational deviance and factors that cause deviance to become routine, rather than idiosyncratic, behavior.

• A permissive ethical climate, an emphasis on financial goals at all costs, and an opportunity to act amorally or immorally, all contribute to managerial decisions to initiate deviance.

Active Event

Reporting

Passive Indicators Discharge

Data

Passive Triggers Medical Records

Truth?

Looking for Harm

Operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through

Wednesdays: 2.94% vs. 2.18%; Odds ratio, 1.36; 95% CI, 1.24–1.49)

No  system

 beyond  this  point  

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways

Chartered Flight

Drilling Industry

Chemical Industry (total)

Fatal risk

Anesthesiology ASA1

Innovative medicine (grafts, oncology …) ICU Trauma centers

Very  unsafe   Ultra  safe  

Professional fishing

Average  rate  per  exposure  of  catastrophes  and  associated  deaths  in  various  industries  and  human  ac'vi'es  

Unsafe   Safe  

Hymalaya mountaineering

Combat A/C, war time

Medical risk (total)

Scheduled surgery Chronic care

Radiotherapy, Biology Blood transfusion

Finance Fire Fighting Food Industry

Processing Industry

Amalberti R. et al.: 5 System barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142:756-764.

Assuming a system is 99.9% safe; How Safe is “Safe Enough” for surgery???

•  84 unsafe landings /day

•  1 major plane crash every 3 days

•  16,000 mail items lost/hr

•  37,000 bank transaction errors/hr

23

24

Slide: 25

“Sprawl is taking a toll on Americans' hearts, lungs, air, drinking water, sense of community, psychological well-being and physical safety.” Frumkin& Jackson The Built Environment & Public Health

“During the Atlanta Olympics, restrictions on single occupancy vehicles correlated with a 30% decrease in emergency room asthma visits.”

© 2009 Perkins+Will

I. Busch-Vishniac, J. West, C. Barnhill, T. Hunter, D. Orellana, R. Chivukula, "Noise levels in Johns Hopkins Hospital," JASA 118 (6), December 2005.

Trends in hospital noise since1960

è

NREM2 , NREM3, REM

Poor acoustics (long reverberation times) might increase medical errors by: l Reducing speech intelligibility, increasing comprehension errors l Increasing staff fatigue and stress l Worsening performance in situations involving high load in

working memory

Model of speech intelligibility in hypothetical “zero reverberation” acoustic conditions

Model of speech intelligibility in short reverberation time acoustic conditions

“If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made” Norman, The Design of Everyday Things, 2001

Guide  to  Human  factors  

•  ‘Hard  Stuff’:    •  people  interac4ng  with  machines  •  People  interac4ng  with  computers  •  People  interac4ng  with  automa4on  

•  ‘SoP  Stuff’:  •  People  working  with  people:  

• Team  performance  • handovers  • Culture  

Barach P, et al. 2013

Reason – Complex Systems

Conceptual model based on Reason’s model showing the role of the environment as a latent condition or barrier to adverse events in health care settings. Sources: Dickerman and Barach (2008); Joseph et al 2008; Patti and Barach (2011); Cassin and Barach (2012); Sanchez and Barach (2012)

Socio-technical approach to safety and quality

Solet J. and Barach P., 2012

Evidence Based Design

Evidence-based design is the deliberate attempt to base building decisions on the best available evidence.

Design decisions are research-informed: §  Patient outcomes §  Patient satisfaction §  Clinical quality and safety §  Staff satisfaction §  Operational efficiency §  Financial performance

The “Rational” Planning Process

Historical UtilizationPatterns

StrategicPlanning

Assumptions

SupportSystems/Services

WorkloadScenarios

EstimateNumber of

O.R.’s

Space andFunctionalProgram

DesignAlternatives/

Cost

Evaluation/Decisions

Analysis ofExisting

O.R.’s/Space

OperationalAnalysis

Ext

erna

l Ana

lysi

sS

ynth

esis

Inte

rnal

Ana

lysi

s

Construction

InfrastructureCapacity

InterventionalComponents

InfectionControl

Assessment

ICRAPlan

TechnologyAssessment

After Zilm F, Tingwald, Barach P.

Nursing Units/Patient Rooms

Cluny 12th C

Friedriks, Copenhagen

Hotel Dieu Ospedale Maggiore, Milan

Antwerp

•  “…the very first requirement in a Hospital [is] that it •  should do the sick no harm.”

•  – Notes on Hospitals, 1863

Florence Nightingale

EBD Perspective

Scutari, former Turkish barracks, 43% die

Crimean Quagmire

The answer: Isambard Kingdom Brunel

Those clever Brits

Military Hospital Ward, Rentkioi

§  Methodical investigation §  Testing (EBD old bloke?) §  Materials selected for cleanliness §  Prefabricated offsite, shipped to Crimea §  Removing waste an issue §  Ventilation 10,000 CFM §  Dramatically improved survival rates – mortality

reduced to 3%

The Result

Nightingale Pavilion St. Thomas Hospital - 1976

2.25%

2.50%

2.75%

3.00%

3.25%

3.50%

3.75%

4.00%

4.25%

Erro

r R

ate

480 lux

Medication Dispensing Error Rates by Illumination Level (Buchanan et al., 1991)

1100 lux 1550 lux (Lighting on task, not ambient)

250 lux

Open bay Old singleroom

New singleroom

0%

60%

50%

40%

30%

20%

10%

27%

38%

47%

28% increase

42% increase

74% total increase

Han

dwas

hing

rat

e Preliminary Findings (Quan and Ulrich, 2005)

Placing alcohol gel dispensers in hallways next to patient doors does not appear to increase hand washing (Muto, Sistrom and Barr, 2000)

For busy preoccupied persons, out-of-sight may be out-of-mind

Old ICU • Combination of open bay

and small single-bed rooms

gel dispenser sink

Four building blocks towards moving Networks towards a “high reliability” healthcare organization

The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value.

‘High reliability’ organizations:

48

After Berg M and KPMG Report

Conceptual Model of Evidence-Based Practice Implementation, Aarons, 2011

Conceptual Model of Evidence-Based Practice Implementation, Aarons, 2011

Value Compass Thinking

•  Do we use these important types of metrics to measure the right things in our Networks?

Results

Satisfaction (Staff and Patients)

Costs

Productivity/Efficiency

Adapted from Nelson et al 2002 51

Challenges in Building Industry Delivery of Services

•  Despite BIM, LEAN, forward thinking, scheduling/costing software, design enhancements

Most projects: •  Run over budget and time •  Expensive •  Controlled by legal tools •  Limited trust between parties •  Maximum uncertainty •  Normalised devaince

Slide: 52

Egan Report (1998), Latham Report (1994), Kashiwagi (2006)

Delivery system of services •  Client wants low price/high value, vendor wants

minimum performing systems •  Price based signals has lower performance because

the client who knows less is giving directions to the vendor who is supposed to be expert

•  When minimum requirements are used in combination with low price awards, the quality degrades, trust is absent, and an adversrial relationship between client and vendor is formed

•  When quality decreases, client’s control increases •  Performance and value decrease with more client

control

Slide: 53

Deming 1982 •  Minimisation of deviation and NOT

minimum standards will lead to optimising value

•  Minimal standards in directions coupled with the award to the lowest bidder results in degeneration of vendor quality and skill

Slide: 54

The Ladder of Inference (Peter Senge)

55

Information Management theory (IMT)

•  Inabiltiy to control, manage, direct others

•  Aligns supply chain to minimise cost and transactions

Slide: 56

Increased performance

•  Recognises the vendor as expert •  Increased vendor accountability •  Preplanning •  Measurement of performance •  Quality and risk management

Slide: 57

Value

•  Quality •  Customer satisfaction •  Project deviations •  Project management •  Risk management efforts •  Price

Slide: 58

Role of the Contract

•  Minimises risk instead of controlling, directing, and inspecting vendor

Slide: 59

Best Value Procurement (BVP) •  Price AND performance vs. Price ALONE •  Limits client control of vendor •  Does not use contract to control the vendor •  Requires vendor to write contract and define delivered product •  Vendors administer their own contract by limiting cost and time

deviations •  Gives the vendor full control of the project •  Minimizes the time and cost to vendors to prepare for

procurement process •  Defines QA as ensuring that the contractor/vendor is running

their quality control/risk management system •  Forces the vendor to communicate in simple, non-technical

language, using performance measurements easily understood by non experts

•  Measures the performance of the other entities in the supply chain that interface with the contractor

Slide: 60

Outcomes of BVP

•  Commodities, professional services, IT •  98% client satisfaction with no vendor

caused deviation •  Minimized up to 90% of the client’s risk

and project management •  Vendor’s increased profits up to 100%

without increasing the cost to the client

Slide: 61

Tools to Facilitate Understanding Steps from the beginning Program (numbers and narrative) Adjacency and Flow Diagrams Plans and Reflected Ceiling Plans Elevations and Equipment Placement 3D Modeling and Scale Models Full Scale Models and Simulation Mock-ups with Equipment and Finishes

Communications Consensus Building

Vision (from the top) Alignment of Surgery/ Medicine Alignment of Surgery/Radiology Cardiac Catheterization buy in Playing by Surgical Rules Code/Operational Issues

Culture Shock

Scenario Modeling Components

Simulation Engine

I

Demographics

Reimbursement

Technology

Service Rates

Affiliations

Staffing Mix

Input Drivers

I

Units of Service

Financial Ratios

Income Statement

Balance Sheet

Quality Measures

Community Engagement

Outcomes Case Mix Productivity

Capacity Financial Performance

Base Line Variables

Behavior Modification Health Education

Risk Mitigation Variables

PCMH Model ACO

Input

Variations

Scenario Development Process

Capture the Schema

Inputs Baseline Outputs

Formal Model

Variables Drivers Implications

Integration

Implications KPIs

Business Model

Performance

Transformation Plan

Knowledgebase

Educ

atio

n

Initi

al R

un

Form

al R

evie

w

Team

Dev

elop

men

t

600 sf O.R.: Net or Gross sq.ft.?

Response   Chart   Percentage   Count  

Net  Square  Feet       31%   99  

Gross  Square  Feet       69%   221  

  Total  Responses   320  

 

After Frank Zilm

 

 ?

Scale of Drawing? AORN

Response   Chart   Percentage   Count  

2  to  4  feet       36%   121  

5  to  6  feet       47%   157  

7  to  8  feet       12%   40  

I’m  not  sure       5%   15  

  Total  Responses   333  

 

Communications Scales of Consensus

The Big Idea (guiding principles) Change as normative (big idea) Establishing a new hierarchy Understanding group loss Leveling an unlevel playing field Establishing small group alliances Understanding individual loss

Tools to Facilitate Understanding Plans and Reflective Ceiling Plans

After George Tingwald

Tools to Facilitate Understanding 3D Modeling

Tools to Facilitate Understanding 3D Modeling

Tools to Facilitate Understanding

3D Modeling

Mock-Up Neuro OR1

Mock-Up OR2

LPCH Mock-Up IMRI

Regenerative Buildings

Living Buildings

“do no harm”

_ = + Regenerative

Buildings

“heal”

+ R

esou

rce

Dep

letio

n +

Res

ourc

e G

ener

atio

n High Performance Green Buildings

“do less harm”

RESILIENCE

© 2009 Green Guide for Health Care

Standard Practice

The future of healthcare

Next frontier -- Wicked Challenges

•  Work sharing •  Infection prevention •  Transitions of care •  Physical room and equipment design •  Culture of safety

Stages in the development of a safety culture

CALCULATIVE We have systems in place to

manage all hazards

PROACTIVE Safety leadership and values drive

continuous improvement

REACTIVE Safety is important, we do a lot every time we have an accident

PATHOLOGICAL Who cares as long as

we're not caught

GENERATIVE (High Reliability Orgs) HSE is how we do business

round here

After Ron Westrum

High Reliability Organizations

•  Environment rich with potential for errors •  Unforgiving social and political

environment •  Learning through experimentation difficult •  Complex processes •  Complex technology

Weick, KE and Sutcliffe, KM, 1999

The Five Dysfunctions of (healthcare) Teams

After Patrick Lencioni, 2007

82

Absence of trust

Fear of Conflict

Commitment

Accountability

Results

Shaping the environment for engagement and loyalty

Employees really enjoy working with one

another but don’t feel particularly challenged.

Here the focus is on collaboration and learning

in the service of high-performance outcomes.

Employees tend to be apathetic and spend

their time jockeying for position.

People fear to offer tentative ideas, try new

things, or ask colleagues for help.

Accountability

Safety

Low

High

Low High

After Amy Edmonson

Ebd 2.0: High priority

research directions

Center for Health Design and HERD Conferences

86

1 Develop an an assessment and evidence implementation program 2 Conduct a noise audit and develop a noise reduction plan

3 Install high performance sound absorbing ceiling tiles

4 Install circadian (cycled) lighting in the NICU

5 Install hand washing dispensers at each bedside & in all patient areas

6 Use virtual reality images and artwork to provide positive distractions

7 Incorporate social networking spaces or age appropriate play areas

8 Improve way finding through enhanced signage

9 Where structurally feasible, install HEPA filters in areas housing immunosuppressed patients

Priority Design Recommendations to Implement ANYTIME

87

1 Build single family patient rooms

2 Provide adequate space for families to stay overnight in patient rooms

3 Build accessible indoor or outdoor gardens

4 Design age appropriate play areas and amenities

5 Increase visual access and accessibility to patients (decentralized nursing stations)

6 Optimize natural light in staff and patient areas

7 Install HEPA filters in areas housing immuno-suppressed patients

8 Install effective way finding systems

9 Install ceiling lifts to reduce workforce injuries

10 Reduce patient transfers through acuity adaptable rooms

Priority Design Recommendations to Implement DURING CONSTRUCTION / RENOVATION

§  Risk of failure is inherent in complex systems §  Risk is always emerging §  All risk is not foreseeable §  People are fallible …no matter how hard they try

not to be §  Systems are fallible §  All care is delivered at the microsystem level §  Hospitals can help to design out the impact of

human errors §  Culture eats strategy for breakfast

A New Model of Procurement

Conclusion

• Barriers to change-culture eats strategy for breakfast (Peter Drucker)

Slide: 89

More •  More on topic and references for talk

see https://www.linkedin.com/in/paulbarach

•  Key research papers are downloadable at Research Gate athttps://www.researchgate.net/profile/Paul_Barach/publications/?pubType=article&ev=prf_pubs_art

•  Email me at pbarach@gmail.com or contact me at Tel: 773 612 7039

Slide: 90