springboard: using knowledge to launch your career- asid gopro 2013

SpringboardUsing Knowledge to Launch Your Career

Rosalyn Cama, FASID, EDAC

Elizabeth Oshana, Allied ASID, EDAC

Erin Peavey, LEED AP BC+D, EDAC

EXPLICIT

MYTH: Design is only for the carriage trade

FACT: What was once privileged is now common

MYTH: Designers have secret sources

FACT: “To the Trade” is now an open source mouse click away

MYTH: A four year degree leads to professionalism

FACT: Requisite for professionalism is a multi-disciplinary graduate education

MYTH: “Trust me” I have an amazing portfolio of award winning work

FACT: Time honored traditions need validation, “Show me results”

What is research?

Research is a systematic investigation of our environments, using a variety of research tools to develop our knowledge providing insight on projects.

How do we “know”?

Tacit Knowledge In our heads, “gut-feeling”

Consciously acknowledged and organized.

5%Explicit Knowledge

How do we “know”?

“The value of research is making the tacit explicit”SALLY AUGUSTINE (2012) The Designer’s Guide to Doing Research

Tacit Knowledge In our heads, “gut-feeling”

Related FieldsEnvironmental PsychologyEnvironment & BehaviorSalutogenic Design (Design for Health)Evidence-based Design

1854Florence Nightingale, Crimean War

1973First Arch. Psych.course, UK at U. of Surrey

1968Environmental Design Research Association (EDRA) formed

1980sRoger Ulrich, Pioneering studies on healing environments

1986Carpman & Grant,Design that Cares

1993Center for Health Design formed

2001Institute of Medicine,Crossing the Quality Chasm

300 BCGreek Healing Temples

1969William Whyte, NYC Behavior Observation

2003Evidence-based design (EBD) defined by Kirk Hamilton

2008Health Environments Research & Design Journal

Environmental Design Research & Health Timeline

HOK Research Services

Primary Research• Facility Evaluations• Behavior Observation• Mock-Ups: Virtual and Physical

Secondary Research• Literature Review• Benchmarking• Guidelines for Hospital System

Infusing Research on ProjectsInnovation & Validation Process

ExistingFacility

NewFacilityInnovateAssess Validate

“If I were given one hour to save the planet, I would spend 59 minutesdefiningtheproblemand one minute resolving it.”ALBERT EINSTEIN

What are clients asking for?

Shared GoalsContinuum of project types

New York Presbyterian

Broad Review of Best Practice

Mercy Hospital System

Critical Literature Review

Mercy Hospital System

On-site Data Collection

Parkland Hospital

Experimentation

Shared Goals

Shared GoalsInstitute of Healthcare Improvement’s Triple Aim

M. STIEFEL & K. NOLAN (2012). A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org)

FOR THE WHOLE POPULATION

THE BEST CARE AT THE LOWEST COST

Cost & ValueSavings from Research-Informed Design

January-February 2011 HASTINGS CENTER REPORT 13

Despite deep and vocal disagreements over health care reform, virtually everyone believes that the current system is not economically sustainable.

We are spending too much and getting too little in re-turn. This recognition has spurred health care leaders to examine every aspect of hospital operations. But what about the health care building itself, the physical envi-ronment within which patient care occurs? Too often, cost-cutting discussions have overlooked the hospital structure. Changes in the physical facility provide real opportunities for improving patient and worker safety and quality while reducing operating costs.

The “Fable hospital,” an imaginary amalgam of the best design innovations that had been implemented and measured by leading organizations, was an early at-tempt to analyze the economic impact of designing and building an optimal hospital facility.1 The Fable analysis, published in 2004, showed that carefully selected de-sign innovations, though they may cost more initially,

could return the incremental investment in one year by reducing operating costs and increasing revenues. Reac-tions to the Fable paper varied. Many felt it presented a compelling case and stimulated health care leaders and architects to think differently about balancing one-time building costs with ongoing operating costs. Oth-ers voiced skepticism about whether the benefits were as great as described and asked for more evidence.

Today, the Fable hospital is no longer imaginary. Dur-ing the past six years, numerous hospitals have imple-mented many of its attributes and have evaluated their impact on patients, families, and staff.2 Several are mem-bers of the Center for Health Design’s Pebble Project, a group of organizations that apply evidence-based de-signs to improve quality and financial performance. Two Pebble hospitals are featured in essays accompanying this article. These and other pioneering organizations and their architecture/design teams are introducing such in-terventions as larger single-patient rooms, which reduce the incidence of health care-associated infections; wider bathroom doors, which reduce patient falls; HEPA filtra-tion and other indoor air quality improvements, which reduce health care-associated infections; appropriate task lighting in medication dispensing areas, which reduces medication-related errors; hydraulic ceiling lifts in pa-tient rooms and bathrooms, which reduce patient and staff lift injuries; and art and music, which reduce anxi-ety and depression and speed recovery.

Since 2004, much has changed that affects decision-making about health care construction and design. It is time for a fresh look at the Fable hospital. Drawing on the latest design and health care knowledge, research, the 2010 health reform law’s emphasis on value and quality improvement, and our collective experience, we present Fable hospital 2.0.

The Changing Health Care Landscape

Five major health care trends are relevant to our analy-sis: the growth of evidence-based design, the safety/

quality revolution, pay for performance and increasing consumer transparency, sustainability and green design, and access to capital.

EssaysEvidence shows that changes in the architecture, design, and decor of health care

facilities can improve patient care and in the long run reduce expenses. These essays detail the state of the research, look inside two hospitals that put some of

these innovations into practice, and consider how design fits into the moral mission of health care.

Fable Hospital 2.0: The Business Case for Building Better Health Care Facilities

BY BlAIR l. SAdlER, lEONARd l. BERRY, ROBIN GuENTHER, d. K IRK HAmIlTON, FREdERICK A. HESSlER, ClAYTON mERRITT, ANd dEREK PARKER

Blair L. Sadler, Leonard L. Berry, Robin Guenther, D. Kirk Hamilton, Frederick A. Hessler, Clayton Merritt, and Derek Parker, “Fable Hospital 2.0: The Business Case for Building Better Health Care Facilities,” Hast-ings Center Report 41, no. 1 (2011): 13-23.

“Fewer payers will reimburse hospitals and physicians for the costs of preventable harm. Building designs that help reduce harm are key elements in a hospital’s survival strategy. ”BLAIR L. SADLER, ET AL (2011). Fable Hospital 2.0: The Business Case for Building Better Health Care Facilities. Hastings Center Report 21, no. 1: 13-23.

20 HASTINGS CENTER REPORT January-February 2011

Table 3. Improved Outcomes and Cost Savings

Wecalculatedthefollowingsavingsbasedonpublishedinformation.Weusedourbestjudgmenttoattributeaportionofthesavingstoevidence-baseddesignimprovementsandattemptedtobeconservative.

Improved Savingsor Calculations DesignDetailsOutcomes Increased Revenue

Patient Falls $1,534,166 300 beds @ 80% occupancy = 240 beds or 87,600 patient days; Acuity-adaptable rooms, larger patient Reduced three falls per 1,000 patient days = 263 falls/year; bathrooms with double-door access, $17,500/fall = $4,602,500 spent on falls/year. patient lifts, decentralized nursing Incidence of falls ranges from 2.3 to 7/1,000 patient days. substations, family/social spaces Average cost of patient falls in hospitals is $17,500.1

Pebble Partner Clarion Methodist Hospital reduced falls by 80%.2 Designfeatureshelpreducefallsbyone-third.

Patient $877,500 25% of 19,500 patient stays are in the ICU/step-down unit. Acuity-adaptable rooms Transfers Assuming one transfer per patient stay, 4,875 transfers x Reduced $300/transfer = $1,462,500 for transfers each year. Average direct cost of one patient room transfer is $300.3

Pebble Partner Clarion Methodist Hospital reduced transfers by 90% in its redesigned cardiac care unit.4 Designfeatureshelp reducetransfersinICU/step-downunitsby60%(assumes no reduction in transfers in medical or surgical units).

Adverse Drug $617,400 0.9 adverse drug events/100 patient days x 87,600 patient days Larger private patient rooms, acuity- Events per year = 788 events/year; assuming 56% are preventable, adaptable rooms, medication task Reduced 441 preventable events x $7,000/event = $3,087,000 spent on area lighting, noise-reduction preventable adverse drug events/year.5 measures, e-ICU One study showed that medication-dispensing errors were reduced by one-third with higher work surface lighting levels.6 Clarion Methodist showed a reduction in medication errors of 70%. Designfeatureshelpreduceadversedrugeventsby20%. Health Care- $355,400 Two health care-associated infections (HAIs)/1,000 patient stays Larger single-patient rooms, hand- Associated x 19,500 patient stays/year = 39 HAIs/year; average incremental hygiene facilities, HEPA filtration, Infections cost/HAI patient = $43,000; 39 x $43,000 = $1,677,000.7 improved indoor air quality8 Reduced Designfeatureshelpreducehealthcare-associated infectionsby20%. Length of $1,092,975 87,600 patient days/4.5 days average length of stay =19,500 Larger windows, increased natural Stay patient stays. One study showed a reduced length of stay of one light, noise-reducing measures, heal- Reduced day/stay as a result of increased access to sunlight.9 ing art, healing gardens Being conservative, we used a half-day reduction: 0.5-day reduction/stay x $1,121/day10 = $10,929,750. Designfeaturescontributetolength-of-stayreductionby10%.

Nursing $478,500 At 5.45 staff/occupied bed, Fable has 1,310 full-time employees, Larger windows, noise-reduction Turnover 395 of whom are nurses; attrition of 14%, or 55 nurses/year x measures, healing art, healing Reduced $60,000 recruiting and training per nurse = $3,300,000 in gardens, staff respite areas, and nursing turnover costs per year. Bronson Methodist Hospital single-patient rooms reduced nursing turnover from 14% (national average) to 10%, a decrease of 29%. Fable reduced nursing turnover by 29%, or $957,000.11 Designfeatureshelpreduceturnovercostsby50%.

Care ExperienceInfluencingExperiencewithEnvironment

% OF PATIENTS RESPONDING WITH “5 - EXCELLENT”

THE CARE I RECEIVED HERE TODAY WAS

THE SERVICE I RECEIVED HERE TODAY WAS

OVERALL MY INTERACTIONS WITH STAFF WERE

OVERALL, MY INTERACTIONS WITH MY DOCTOR WERE

70.9%38.9%

58.2%27.8%

50.9%25%

74.5%61.1%

“...patients perceived their overall quality of care as better in the more attractive physical environment.”F. BECKER & S. DOUGLASS (2008). The ecology of the patient visit: Physical attractiveness, waiting times, and the perceived quality of care, J. Ambulatory Care Management, 31(2), 128-141.

HOK Research Projects

System Guidelines

Develop hospital unit guidelines based on:

� Research literature � Investigation of

existing Mercy facilities

� Case studies/benchmarks of other existing facilities

Customer Experience

� Positive distraction & day lighting � Social support & family-centered care � Acoustical privacy & noise reduction � Staff fatigue & satisfaction

Safety

� Unit visibility � Continuum of care post-hospital � Virtual connectivity & care � Infection control � Reduction of toileting-related falls � Reduced staff injury (MSI)

EfficientOperations

� Eliminated wasted time & travel � Point-of-care testing for rapid results � Pod-based unit planning to transform

care at bedside � Charting location to increase staff at

bedside

Standardization & Flexibility

� Spatial flexibility � Operational flexibility � Room standardization

VA Design Guidelines & Call for Research

ExistingBuilding

Design GuidesPOE

Future Building

VADefinedBenefitsofPOE:• Customer Satisfaction emphasized• Performance and Facility Functionality• Standards incorporating Lessons Learned

“Potential recommendations may result in change in policy and guidelines. ”

DESIGNHow does provider/exam space configuration impact staff collaboration, concentration, efficiency and patient perception of care?

RESEARCHHow can we measure this impact with minimum disruption to care and flow of work?

Patient-Aligned Care Team (PACT) Model

Evidence-based Design

The process of basing decisions about the built environment on credible research to achieve the best possible outcomes.

Evidence-based Design

The process of basing decisions about the built environment on credible research to achieve the best possible outcomes.

Efficient & Effective

Experiential

To Err is Human

PRIVATE ROOM300 SQ FT

Infection Control | Private Room

LIKE-HANDED

Medical Error | Standardization

LIKE-HANDED

HAND WASHING SINK AT ENTRY

Infection | Sink Location

TOILET LOCATED ON HEADWALL

SLIDINGDOOR

LIKE-HANDED

Patient Falls | Toilet Location

SLIDINGDOOR

LIKE-HANDED

VARIABLE-ACUITY HEADWALL

Transfers | Variable-acuity Headwall

SLIDINGDOOR

LIKE-HANDED

NURSE SERVER

StaffEfficiency|NurseServer

SLIDINGDOOR

LIKE-HANDED

NURSE SERVER

WARDROBE W/ LOCKABLE STORAGE

FAMILY ZONE ROOMING-IN

FLAT SCREEN TV

Satisfaction | Family Zone

SLIDINGDOOR

LIKE-HANDED

NURSE SERVER

WARDROBE W/ LOCKABLE STORAGE

FAMILY ZONE ROOMING-IN

FLAT SCREEN TV

DAYLIGHT & VIEWS

Depression, Sleep | Daylight & Views

Efficient&Effective

Registered nurses have an annual turnover rate averaging 20%

PATIENT CARE ACTIVITIES

ASSESSMENT / VITALS

CARE COORDINATION

MEDICATION ADMINISTRATION

DOCUMENTATION

Access | Unit Design

“Nursesaretheprimaryhospitalcaregivers.Increasingtheefficiencyand effectiveness of nursing care is essential to hospital function and the delivery of safe patient care.”ANN HENDRICH (2008). The ecology of the patient visit: Physical attractiveness, waiting times, and the perceived quality of care, J. Ambulatory Care Management, 31(2), 128-141.

Access | Unit Design

Efficiency|PerchPod

Injury | Patient Lifts

Satisfaction | Daylight

Experiential

Treat the whole person, not just the disease

Stress | Positive Distractions

Social Support | Family Zone

Social Support | Family Lounges

Stress|WayfindingLandmarks

Perception of Wait Times | Comfort

Communication | Talking Rooms

Efficient & Effective

Experiential

Restorative

What’s next?

PETER CAREY (2013). KI & IIDA NY Healthcare Forum: Resilience As Sustainability. Teknion Office Insights. Issue: 9-30-2013, (3).

MYTH 1: Design is only for the carriage trade

FACT: What was once privileged is now common

“Globalization 3.0 is shrinking the world from a size small to asizetinyandflatteningtheplayingfieldatthesametime.”THOMAS L. FRIEDMAN (2005). The world is flat. New York: Farrar, Strauss and Giroux.

Project Wisdom

ConstituencyIntelligence

Thought LeadersIntelligence

Institutional Intelligence

DesignIntelligence

ResearchIntelligence

Vision Keeper

ORIENTED TOTHE FUTURE

ORIENTED TOTHE PRESENT

VALUESDRIVEN

ECONOMYDRIVEN

GET HERE 2

VALUES (BELIEF)

VALUE $$$

LAG - BASELINEINNOVATE

GET HERE

Determinants of Decision Making

MYTH: Designers have secret sources

FACT: “To the Trade” is now an open source mouse click away

“...translators take ideas and information from a highly specialized world and translate them into a language the rest of us can understand.”MALCOLM GLADWELL (2000) The Tipping Point. Boston: Little, Brown and Company.

Outcome as the driver for design solutions

MYTH: A four year degree leads to professionalism

FACT: Requisite for professionalism is a multi-disciplinary graduate education

“But epiphanies rarely occur in familiar surroundings. The key to seeing like an iconoclast is to look at things you have never seen before. It seems almost obvious that breakthroughs in perception do not come from simply staring at an object and thinking harder about it. Breakthroughs come from a perceptual system that is confronted with something that it doesn’t know how to interpret.”GREGORY BERNS (2008). Iconoclast. Boston: Harvard Business Press.

“Opposite of beauty is injury not ugliness.””ELAINE SCARRY (1999). On Beauty and Being Just. Princeton: Princeton University Press.

MYTH: “Trust me” I have an amazing portfolio of award winning work

FACT: Time honored traditions need validation, “Show me results”

“Unselfconscious cultures contain, as a feature of their form producingsystems,acertainbuilt-infixity–patternsofmyth, tradition and taboo which resist willful change. Form builders will only introduce change under strong compulsion where there are powerful (and obvious) irritations in the existing forms which demand correction.”CHRISTOPHER ALEXANDER (1964). Notes on the synthesis of form. Cambridge: Harvard University Press.

CALL TO ACTION

The Future of the Interior Design Profession is on a springboard...

Interiors need to be created within an interdisciplinary team using evidence-based hypothesized outcome driven solutions for all who inhabit built environments

Interior Designers need to be translators of productive, safe, resilient environments for the betterment of mankind

Post graduate programs need to evolve around a finite group of topics that can build a strong foundation for the profession and all whom we serve

A shift in practice methodology must lead to evidence-based design

Post graduate programs need to evolve around a finite group of topics that can build a strong foundation for the profession and all whom we serve

Thank you.Questions?

For a copy of this presentation please visit camaincorporated.com

springboard: using knowledge to launch your career- asid gopro 2013

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