functionalandspatialdesignofemergencydepartments...

Research ArticleFunctional and Spatial Design of Emergency DepartmentsUsing Quality Function Deployment

Yassin Abdelsamad Muhammad Rushdi and Bassel Tawfik

Department of Biomedical Engineering and Systems Faculty of Engineering Cairo University Giza 12613 Egypt

Correspondence should be addressed to Yassin Abdelsamad yassin_bmeyahoocom

Received 20 July 2018 Accepted 18 October 2018 Published 14 November 2018

Guest Editor Evangelia Chrysikou

Copyright copy 2018 Yassin Abdelsamad et al is is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Inadequate design of emergency departments (EDs) is a major cause of crowding increased length of stay and higher mortalitye main reason behind this inadequacy is the lack of stakeholdersrsquo involvement in the design process is work reports andanalyzes the results of a large survey of the requirements of ED stakeholders It then compares these requirements with existingdesigns on the one hand and international standards on the other Further we propose a new hybrid design which combines therequirements of both the stakeholders and international standards using quality function deployment (QFD) also known as theHouse of Quality method e proposed method was used to assess two existing EDs located in two countries e analysis of thesurvey responses showed certain discrepancies between stakeholder requirements and the existing designs such as the absence ofan initial admission unit and insufficient space of the treatment unit e results showed a strong correlation between the QFD-based design and stakeholder requirements (r 092 for ED1 and r 093 for ED2) which is attributed to the incorporation ofstakeholdersrsquo opinions into the QFDmethode new design was also positively correlated to the international standards (r 094for ED1 and r 091 for ED2) Our findings suggest that international design standards should be based on more structuredmethods for incorporating stakeholdersrsquo views and that a certain degree of difference should be allowed depending on the regionin which the hospital is located to reflect both cultural and environmental differences

1 Introduction and Background

e emergency department (ED) plays an important role inproviding patients with prompt and effective clinical care[1] It is the healthcare entry point responsible for receivingsorting assessing stabilizing and managing patients ar-riving at its door with different degrees of urgency andcomplexity Conditions of patients requiring an emergencycare vary from major trauma and stroke to intoxication andmental disorders [2 3] erefore ED is considered to be anextremely complex system [4] Yet its design has witnessedlittle even if no progress in recent years to cope with thesecomplexities efficiently and cost-effectively

Improper facility design can lead to numerous problemsIn the ED in particular crowding is a prominent problem[5ndash7] As addressed by Carter et al [8] crowding is asso-ciated with increased patient mortality poor quality of care

extended waiting times increased rates of patients leftwithout being seen (LWBS) and extended length of stay(LOS) In addition to crowding many healthcare pro-fessionals find current EDs incapable of meeting the ex-pectations of patients their families and the medical staff

To alleviate these ED problems Welch [9] listeda number of factors that could improve the quality of EDservice Some of these factors involved human resources(such as the incorporation of medical teams) administra-tional controls (such as creating express admission units)and architectural design issues (such as the creation of intakepods zones and discharge kiosks) Chan et al [10] appliedlean methodologies to improve the ED design

Kolb et al [11] proposed a five-buffer system to relievepressure in the ED is system reduced the triage-to-bedtime by up to 22 decreased the diversion by up to 24increased patient satisfaction and improved the process

HindawiJournal of Healthcare EngineeringVolume 2018 Article ID 9281396 7 pageshttpsdoiorg10115520189281396

ow Tawk et al [12] used computerized relationship layoutplanning (CORELAP) to construct ED designs and createa new layout that includes major ED spaces Results showeda reduction in patient crowding and an improvement inpatient ow

Although some of these studies involved stakeholdersrsquoopinions such involvement was not integrated into thedesign process in a systematic and ordered way One of themost popular methods known for involving stakeholderrequirements is the quality function deployment (QFD)method also known as the House of Quality (HoQ) [13 14]is method developed by Toyota in the early Sixtiestranslates the customer requirements into appropriatetechnical specications It is one of the total quality man-agement (TQM) tools [15] e ultimate goal of QFD is totranslate the subjective design criteria into objective ones tocomplete the design process in a systematic mannerImplementation of QFD takes four steps or phases namely(1) product planning (2) parts design (3) process planningand (4) production planning [16]

e House of Quality (HoQ) is a widely used form ofQFD which consists of six rooms (Figure 1) e rst roomldquoArdquo contains the customer requirements e assessment ofcustomer requirements against business competitors takesplace in room ldquoBrdquo Room ldquoCrdquo has the technical character-istics which are a translation of customer needs whereasroom ldquoDrdquo includes the values of correlation between eachcustomer requirement and technical specications e roofldquoErdquo shows how the design specications support each othere calculation of priorities of technical targets is done inroom ldquoFrdquo [15 17]

e HoQ has been traditionally used in themanufacturing business with the aim of systematically in-corporating stakeholdersrsquo needs in future designs Since thedesign process is fundamentally the same whether it isa machine or a facility the HoQ methodology was extendedto enhance the architectural design of a new childrenrsquosnursery and in the design phase of an apartment con-struction project [17ndash19]

e objective of this paper is twofold Firstly we seek totake the quality function deployment (QFD) methodologyone step further and apply it to propose a stakeholder-baseddesign for the healthcare facilities Secondly we demonstratethe outcomes of the QFDmethodology in the ED designWehave started with the ED not only because of its importancebut also for its complexity which makes it a challengingquest Towards this objective we have collected the re-quirements of a large sample of ED stakeholders in twocountries in theMiddle East We have then implemented theHoQ methodology in order to obtain an improved designover the existing ones In doing so we have made use ofsome of the most commonly used international standards(IS)

2 Materials and Methods

As shown in Figure 2 the QFD-based ED design processseeks to identify and prioritize the ED functional units basedon both stakeholder requirements (SR) and international

standards (IS) Other design aspects such as environmentalconsiderations operational models and architectural re-quirements are outside the scope of this work

e new QFD-based design is obtained through thefollowing steps

21 Step 1 Listing Stakeholder Requirements First of alla focus group of ED stakeholders in Egypt and Saudi Arabiaincluding patients was asked to mention those needs thatthey believe are important to improve the ED design e-ciency and patient satisfaction In addition other conceptson ED design were collected from the guidelines of theAustralasian College for Emergency Medicine [1] theAustralasian Health Facility Guidelines [2] ED patient owguidelines ([5 9]) and ED overcrowding reduction concepts[11] ese concepts were used along with the inputs of thefocus group to build a questionnaire of 84 items

en we classied the survey items into eight groupsnamely (1) basic services (2) requirements to streamline thematerial ow (3) requirements to streamline the patientow (4) clinical support services (5) consultation services(6) areas to support the diagnostic services (7) patientholding areas and (8) areas for stapound support and teaching

e survey was then conducted for two months among118 ED stakeholders all of whom at the time of the surveywere working in either Egypt or Saudi Arabia e stake-holders can be roughly divided into two main groups erst one includes strongly-aliated ED stapound (eg physiciansnurses administrators and technicians) whereas the secondgroup includes loosely-aliated professionals who do notwork inside the ED but are linked to it (eg clinical engi-neers healthcare planners pharmacists and non-EDphysicians)

Out of 118 subjects 108 completed the questionnairewith a response rate of 915e respondents were asked torate the questionnaire items based on a 5-point importancescale (0 not important 1 slightly important 2 moderately important 3 important and 4 extremelyimportant) en the average importance value of each itemwas calculated and converted into a percent score

(F)Technical targets

(A)

Custo

mer

nee

ds

(D)Relationship matrix

(C)Design specifications

(E)Roof

(B)

Plan

ning

mat

rix

Figure 1 e House of Quality

2 Journal of Healthcare Engineering

22 Step2Developmentof theDesignSpecications is stepis to translate the SR into relevant design specications (DS)based on (1) brainstorming among experienced healthcareplanners (2) international guidelines and (3) review of theliterature Table 1 shows the proposed design specicationswith their functions

23 Step 3 Construction of the Relationship Matrix erelationshipmatrix is the core of the QFDmethodologyismatrix maps the correlation between SR and DS Accordingto Franceschini et al [20] a 3-point ordinal scale (ldquoweakrdquoldquomediumrdquo and ldquostrongrdquo) establishes the values of the re-lationship matrix using two series (0 1 3 and 9 or 0 1 3and 5) e rst series is derived from a logarithmic intervalscale with 3 as a basis while the second is derived froma linear interval scale If the ratings derived from a linearinterval scale are interpreted as being derived from a pro-portional scale this can lead to a wrong priority rank ofdesign specications [20] In this QFD-based method weused the linear interval scale as (1 low 5 medium and 9 high)

A correlation value reects how a design specicationsupports the purpose of a particular SR For example asshown in Figure 2 the wounded patients who do not needadditional treatment in the arrival unit (fast track) can bemanaged by allocating a temporary bupounder and discharge unitto hold those patients until discharge

24 Step 4 Construction of the Correlation Matrix (Roof)is matrix shows how the design specications supporteach other to identify the bottlenecks and trade-opound e six-point scale has been used in this study in which +9 representsstrong positive correlation while -9 represents a strong

negative correlation For example the correlation between(the Initial Admission and Disaster Management Unit) and(the Diagnostic Zone) is +3 is means that if the space ofthe rst zone increased the space of the second zone shouldbe fairly increased as well

25 Step 5 Development of the PlanningMatrix In the QFDliterature [17 21] the planning matrix includes the as-sessment of features of existing products against those ofcompetitors We modied this matrix to make the QFDmethodolgy more suitable for healthcare facility design emodied matrix includes the spaces of each serviceaccording to the existing design SR and recommendation ofthree IS namely Australasian Health Facility Guidelines(AusHFG) [2] National Health Service (NHS) [22] andUnited States Department of Defense (DoD) [23] Here arethe steps to create the planning matrix

(1) Calculate the average importance Ii of each re-quirement from the questionnaire responses

(2) Calculate the existing space Ei of each requirementusing the schematic diagram

(3) Find the space (Sis) of each requirement according to(AusHFG NHS and DoD)

(4) Compare Ei with Sis for each requirement(5) Set the target area Ti for each requirement as the

average value of the three IS(6) Calculate the improvement ratio IRi as

IRi Ti minusEi (1)

where Ti and Ei are the target and the existing spaces for theith requirement

ndash3

1 9

3 3 90 1 3 9

1 3 3 3 3

1 1 1 1 1 1

0 1 3 3 1 0 1

11 Triage in the initial admission zone 426 9 9 1 1 1 0 X X X 241 241 10259 7112 Reception and registration area 403 5 9 5 1 1 294 20 10 111 137 ndash157 ndash6324 ndash44

115 Clean and dirty utility area 408 5 1 5 9 64 22 24 195 218 154 6293 43116 Area for staff offices (private and shared) 389 5 5 1 9 183 20 13 1115 147 ndash36 ndash1396 ndash1022 Holding area for wheelchairs in the walk-in entrance 250

11 9 0 X X 27 27 27 676 05

61 Kids playing area (playground) 135 9 72 10 13 111 114 42 561 04

66 Waiting area for patients planned for fast track 250 9 0 10 X X 100 100 2499 17

67 Wounded patients holding area 267 5 5 0 X X X 40 40 1066 07

68 Patientsrsquo temporary stay area 243 5 5 5 9 0 X X X 150 150 3641 25711 Seminar room 156 9 204 X 375 223 299 95 1484 10

712 Valet parking for staff 247 5 9 9 9 0 X X X 60 60 1480 10

1004 Priorities 104 396 505 227 069 094 213 255 1863

100

14472428299

5 Weight 56 213 271 122 37 50 114 137

Targ

et (T

)

Dia

gnos

tic zo

ne

Supp

ort s

ervi

ces z

one

Exi

sting

spac

es (E

)

Support services zone

Administrative zone

Abso

lute

wei

ght (

AW)

1 AHFG

Initial admission and disaster managing zone

Patient arrival zone

Treatment and admission zone

Diagnostic zone

Temporary buffer and discharge zone

Surgical zone

3 DoD

Trea

tmen

t and

ad

miss

ion

zone

1 Stakeholder requirements

2 Planning matrix (competitive assessment)

Relat

ive w

eigh

t (R

W)

Adm

inist

rativ

e zon

e

Impr

ovem

ent r

atio

(IR)

Surg

ical

zone

2 NHS

Tem

pora

ry b

uffer

and

disc

harg

e zon

e

Initi

al ad

miss

ion

and

disa

ster m

anag

ing

zone

Patie

nt ar

rival

zone3 Design

specs

International guidelinesfor ED design

Figure 2 Part of the HoQ matrix for the QFD-based emergency department design

Journal of Healthcare Engineering 3

(7) Calculate the absolute weight AWi as

AWi IRi lowast Ii (2)

where IRi and Ii are the improvement ratio and importancescore of the ith requirement respectively

(8) Calculate the relative weight RWi as

RWi AWi

1113936ni1AWi

lowast100 (3)

where n is the number of SR

26 Step 6 Calculation of the Technical Targets For the finalstep of HoQ the technical target matrix contains thetechnical priority TP and weight W of each functional unite technical priority is calculated as

TPj 1113944nm

ij1Cij lowastRWi (4)

where Cij is the correlation value between requirement i andspecification j RWi is the relative weight and n and m

represent the numbers of SR and design specificationsrespectively

e weight Wj is given by

Wj TPj

1113936mj1TPj

(5)

where TPj is the technical priority of design specification j

and m is the number of the design specifications

3 Results and Discussion

31 Survey Results (Stakeholder Requirements) e datacollected from the questionnaire were analyzed using SPSSQualitative data were presented through numbers andpercentages Quantitative data were presented using thearithmetic mean standard error of the mean and standarddeviatione chi-squared test was used to test the statisticalsignificance of the differences between qualitative data eKolmogorov test was done to test the linearity of quantitativevariables Parametric variables were compared between the

two groups using the independent sample t-test Non-parametric variables were compared between the two groupsusing the MannndashWhitney test

Table 2 shows some demographic characteristics of therespondentsemajority of respondents are ED physiciansworking in general hospitals with 5 to 10 years of ED ex-perience and they are dealing with ED patients on a dailybasis A high percentage of respondents (722) did notparticipate in the ED design phases before which is anindicator of the absence of stakeholder voices duringplanning phases in these countries

e responses in Table 3 showed that the most importantrequirement was the allocation of a suitable space for theresuscitation and trauma room whereas the lowest one wasthe allocation of enough space for a library e respondentsreported that many patients admitted to the ED can betreated outside erefore they rated the triage-of-initial-admission unit as highly important e aim of such triage isto decide if patients will be treated in this ED or they will bedirected to other medical services

32 Results of the Proposed QFD-Based ED Design MethodeQFD-based design method was applied on two EDs withthe same trauma category (level-4 trauma) e first de-partment (ED1) is located within a general hospital with 300beds in Saudi Arabiais department includes 17 treatmentbeds and receives around 125000 patients annually esecond department (ED2) is located at a general hospitalwith 365 beds in Egypt It includes 8 treatment beds andreceives around 73000 patients annually

e stakeholders in both countries were asked to answerthe questionnaire and mention any additional re-quirements that could improve the ED design andstreamline the flow of an ED (with 4th trauma level) Forthe two EDs the stakeholders assigned different scores forthe same requirements e statistical comparison betweenresponses of stakeholders from both departments showed(1) a positive linear relationship between responses (r

085) with a significant correlation (plt 0001) (Figure 3)(2) nonsignificant differences in 75 requirements andsignificant differences in 9 requirements and (3) no sig-nificant difference in the demographic data of respondentsfrom both countries

Table 1 Design specifications for QFD-based ED design and their functions

Design specification Function

Initial admission and disaster management Register and sort all patients coming to ED to decide if they will be treated in this EDor will be directed to other medical services is zone must be disaster-ready

Patient arrival Receive register identify the level of urgency and handle ED patients upon arrival

Patient treatment and admission Provide care for unstable and critical patients and low-acuity patients who stay formore than 2 hours

Diagnostic unit Radiology and laboratory testsSurgical unit Plastering performing minor procedures and patient recoverySupport services Equipment storage dirty and utility rooms general stores etcAdministrative unit Staff offices stations change rooms lounge seminar room and library if needed

Temporary buffer and discharge Hosting patients who need less treatment or are waiting for transportation or aregoing to be admitted to inpatient care


e steps of the proposed QFD-based design method(mentioned earlier in Section 2) were then applied to cal-culate the weights and priorities of functional units (Table 4)e results showed that the same functional unit may attaindipounderent ranks in dipounderent departments according to thecontribution of the functional unit to the mission criticality

To validate the results we calculated the dipounderence ratiosRu between the SR and each of (1) the existing design (EXG)and (2) the QFD-based design is dipounderence is calculatedfor each functional unit as follows

Ru Adu minusAsru( )Asru

(6)

where Asru is the area recommended by stakeholders fora given functional unit u and Ad u is the area according tothe existing design or QFD-based design

Figure 4 shows a big discrepancy between SR and theEXG (black line) in most ED functional units for bothdepartments e absence of some functional units fromexisting designs leads to a negative 100-percent ratio eQFD method (dashed line) showed improved dipounderenceratios for both departments

In general the results showed a signicant linear re-lationship between the results obtained by QFD-based de-sign method and the stakeholder needs (r 092 for ED1 andr 093 for ED2) In spite of this linear relation some unitsobtained dipounderent weights compared to the stakeholderevaluation to satisfy the IS e results of the QFD-based

Table 2 Some of the demographic characteristics of respondents

Demographic data of respondents (stakeholders)Valid sample (N 108)

No Country they work inKSA 59 546Egypt 49 454ProfessionClinical engineer 25 231Medical planner 20 185Nursepharmacist 12 111ED physician 39 361Non-ED physician 12 111Years of experience within EDNone 14 130lt5 34 3155ndash10 44 40710ndash15 9 8315+ 7 65Frequency of interaction with patients in the EDSeldom 31 287On consultation 31 287Daily 46 426Participation in ED designNo 78 722Yes 30 278

0

20

40

60

80

100

0 20 40 60 80 100

SR-E

D2

SR-ED1

y = 10183x ndash 003Rsup2 = 072p lt 0001

Figure 3 Scatter plot showing a signicant correlation (r 085)between SR of the two departments reported in this study (ED1 andED2)

Table 3 A sample of survey responses showing the mean importance of some ED requirements

No Stakeholder requirements Mean importance () Std error of mean Std deviation1 Trauma and resuscitation room 9143 181 17932 Triage in the initial admission unit 8449 196 19383 Wounded patients holding area 6506 303 27594 Ambulance entrance store 6437 336 31355 Dental room 3614 333 30316 Kids playing area (playground) 3434 331 30177 Library 3293 336 3040


design method showed a positive correlation to the IS (r 094 for ED1 and r 091 for ED2) Design and planningteams can use the resulting weights and ranks to allocateincrease and decrease areas of some functional units tosatisfy the stakeholders streamline the ow within the EDand to alleviate the crowding problem

4 Conclusion

e QFD method was developed to assign priorities andweights for the ED functional units If spaces or budgets arenot enough to cover all units of ED the medical planners canuse this prioritization scheme for paying the appropriateattention to each unit based on its weight e main goal ofthis work was to reassess the major design solutions for EDthat would improve the owwithin the ED based on both theSR and IS e adaptation and implementation of the QFDmethod helped in introducing a simple and realistic conceptdesign that could achieve that goal is is due to the abilityof QFD to translate the stakeholder needs into designrequirements

e main challenge of the proposed method was thereliance on experts to develop the relationship matrix Ourframework is exible to be used for any ED and it cangenerate variable weights and priorities for the same unitsover time As we did not identify the subunits (components)of each functional unit in this work the medical plannerscan identify these subunits based on the operational modeltypes of patient conditions and the location of each hospitalA separate future work shall use the second phase of QFD tofocus on the identication and prioritization of the subunitsto propose a complete list of ED services

Data Availability

e data used to support the ndings of this study areavailable from the corresponding author upon request

Conflicts of Interest

e authors declare that there are no conicts of interestregarding the publication of this paper

Table 4 Priorities and relative weights of design specications (functional units) according to the QFD-based design method for the twoemergency departments reported in this work (ED1 and ED2)

Functional unitsED1 ED2

Relative weight () Rank Relative weight () RankPatient treatment and admission 271 1 151 3Patient arrival 213 2 286 1Temporary bupounder and discharge 137 3 59 6Diagnostic unit 122 4 181 2Administrative unit 114 5 113 4Initial admission and disaster management 56 6 56 7Support services 50 7 52 8Surgical unit 37 8 101 5

ndash200ndash150ndash100

ndash500

50100150200

Diff

eren

ce ra

tio

ED functional units for ED1

R (EXG SR)R (QFD SR)

Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(a)



ndash500

50100150200

Diff

eren

ce ra

tio


Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(b)

Figure 4 Dipounderence ratios Ru for (a) ED1 and (b) ED2 e black line represents Ru between areas of existing design (EXG) and areasaccording to stakeholder requirements (SR) e dashed line represents Ru between areas obtained by the QFD-based design and areasaccording to SR


References

[1] Australasian College for Emergency Medicine EmergencyDepartment Design Guidelines Australasian College forEmergency Medicine Melbourne Australia 2014

[2] Australasian Health Infrastructure Alliance (AHIA) Aus-tralasian Health Facility Guidelines (AHFG) Version 6Australasian Health Infrastructure Alliance North SydneyNSW Australia 2016

[3] Herman Miller for Healthcare Graphic Standards Pro-gramming and Schematic Design Herman Miller forHealthcare Zeeland MI USA 1999

[4] A Boyle K Beniuk I Higginson and P Atkinson ldquoEmer-gency department crowding time for interventions and policyevaluationsrdquo Emergency Medicine International Journal vol2012 Article ID 838610 8 pages 2012

[5] P R E Jarvis ldquoImproving emergency department patientflowrdquo Clinical and Experimental Emergency Medicine vol 3no 2 pp 63ndash68 2016

[6] Ayed A AL-Reshidi ldquoContributing factors to patientsovercrowding in emergency department at king saud hospitalUnaizah KSArdquo Journal of Natural Sciences Research vol 3no 13 2013

[7] A K Erenler S Akbulut M Guzel et al ldquoReasons forovercrowding in the emergency department experiencesand suggestions of an education and research hospitalrdquoTurkish Journal of Emergency Medicine vol 14 no 2pp 59ndash63 2014

[8] E J Carter S M Pouch and E L Larson ldquoe relationshipbetween emergency department crowding and patient out-comes a systematic reviewrdquo Journal of Nursing Scholarshipvol 46 no 2 pp 106ndash115 2013

[9] S J Welch ldquoUsing data to drive emergency departmentdesign a metasynthesisrdquo HERD Health Environments Re-search and Design Journal vol 5 no 3 pp 26ndash45 2012

[10] H Y Chan S M Lo L L Y Lee et al ldquoLean techniques forthe improvement of patientsrsquo flow in emergency departmentrdquoWorld Journal of Emergency Medicine vol 5 no 1 2014

[11] E M W Kolb S Schoening and T Lee ldquoReducing emer-gency department overcrowding - five patient buffer conceptsin comparisonrdquo in Proceedings of Winter SimulationConference Miami FL USA December 2008

[12] B Tawfik B K Ouda and A Abou-Alam ldquoOptimal design ofemergency department in mass disastersrdquo Journal of ClinicalEngineering vol 39 no 4 pp 175ndash183 2014

[13] L-K Chan and M-L Wu ldquoQuality function deploymenta comprehensive review of its concepts andmethodsrdquoQualityEngineering vol 15 no 1 pp 23ndash35 2002

[14] J R Hauser A Griffin and R L Klein Quality FunctionDeployment (QFD) Wiley International Encyclopaedia ofMarketing North Sydney NSW Australia 2010

[15] N Saleh A A Sharawi M Abd Elwahed A PettiD Puppato and G Balestra ldquoPreventive maintenance pri-oritization index of medical equipment using quality functiondeploymentrdquo IEEE Journal of Biomedical and Health In-formatics vol 19 no 3 pp 1029ndash1035 2014

[16] M L Singgih D L Trenggonowati and P D KarningsihldquoFour phases quality function deployment (QFD) by con-sidering kano concept time and manufacturing costrdquo inProceedings of 2nd International Conference on Engineeringand Technology Development (ICETD 2013) LampungIndonesia August 2013

[17] D J Delgado-Hernandez K Elizabeth Bampton andE Aspinwall ldquoQuality Function Deployment in ConstructionrdquoConstruction Management and Economics vol 25 no 6 2007

[18] L A Gargione Using Quality Function Deployment (QFD) inthe Design Phase of an Apartment Construction ProjectUniversity of California Berkeley CA USA 1999

[19] N Haron L Mohd Khairudin and Farah ldquoe application ofquality function deployment (QFD) in the design phase ofindustrialized building system (IBS) apartment constructionprojectrdquo European International Journal of Science andTechnology vol 1 pp 56ndash66 2012

[20] F Franceschini and A Rupil ldquoRating scales and prioritizationin QFDrdquo International Journal of Quality and ReliabilityManagement vol 16 no 1 pp 85ndash97 1999

[21] B M Deros N Rahman M N Ab Rahman A R Ismail andA H Said ldquoApplication of quality function deployment tostudy critical service quality characteristics and performancemeasuresrdquo European Journal of Scientific Research vol 33no 3 pp 398ndash410 2009

[22] National Health Service HBN 22 Accident and EmergencyFacilities for Adults and Children National Health ServiceNorth Sydney NSW Australia 2013

[23] Defence Health Agency Facilities Division DoD SpacePlanning Criteria Emergency and Ambulance Services De-fence Health Agency Facilities Division Falls Church VAUnited States 2017


International Journal of

AerospaceEngineeringHindawiwwwhindawicom Volume 2018

RoboticsJournal of

Hindawiwwwhindawicom Volume 2018


Active and Passive Electronic Components

VLSI Design



Shock and Vibration


Civil EngineeringAdvances in

Acoustics and VibrationAdvances in



Electrical and Computer Engineering

Journal of

Advances inOptoElectronics

Hindawiwwwhindawicom

Volume 2018

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018

Control Scienceand Engineering

Journal of



Journal ofEngineeringVolume 2018

SensorsJournal of



RotatingMachinery


Modelling ampSimulationin EngineeringHindawiwwwhindawicom Volume 2018


Chemical EngineeringInternational Journal of Antennas and

Propagation




Navigation and Observation


Hindawi

wwwhindawicom Volume 2018

Advances in

Multimedia

Submit your manuscripts atwwwhindawicom

ow Tawk et al [12] used computerized relationship layoutplanning (CORELAP) to construct ED designs and createa new layout that includes major ED spaces Results showeda reduction in patient crowding and an improvement inpatient ow

Although some of these studies involved stakeholdersrsquoopinions such involvement was not integrated into thedesign process in a systematic and ordered way One of themost popular methods known for involving stakeholderrequirements is the quality function deployment (QFD)method also known as the House of Quality (HoQ) [13 14]is method developed by Toyota in the early Sixtiestranslates the customer requirements into appropriatetechnical specications It is one of the total quality man-agement (TQM) tools [15] e ultimate goal of QFD is totranslate the subjective design criteria into objective ones tocomplete the design process in a systematic mannerImplementation of QFD takes four steps or phases namely(1) product planning (2) parts design (3) process planningand (4) production planning [16]

e House of Quality (HoQ) is a widely used form ofQFD which consists of six rooms (Figure 1) e rst roomldquoArdquo contains the customer requirements e assessment ofcustomer requirements against business competitors takesplace in room ldquoBrdquo Room ldquoCrdquo has the technical character-istics which are a translation of customer needs whereasroom ldquoDrdquo includes the values of correlation between eachcustomer requirement and technical specications e roofldquoErdquo shows how the design specications support each othere calculation of priorities of technical targets is done inroom ldquoFrdquo [15 17]

e HoQ has been traditionally used in themanufacturing business with the aim of systematically in-corporating stakeholdersrsquo needs in future designs Since thedesign process is fundamentally the same whether it isa machine or a facility the HoQ methodology was extendedto enhance the architectural design of a new childrenrsquosnursery and in the design phase of an apartment con-struction project [17ndash19]

e objective of this paper is twofold Firstly we seek totake the quality function deployment (QFD) methodologyone step further and apply it to propose a stakeholder-baseddesign for the healthcare facilities Secondly we demonstratethe outcomes of the QFDmethodology in the ED designWehave started with the ED not only because of its importancebut also for its complexity which makes it a challengingquest Towards this objective we have collected the re-quirements of a large sample of ED stakeholders in twocountries in theMiddle East We have then implemented theHoQ methodology in order to obtain an improved designover the existing ones In doing so we have made use ofsome of the most commonly used international standards(IS)

2 Materials and Methods

As shown in Figure 2 the QFD-based ED design processseeks to identify and prioritize the ED functional units basedon both stakeholder requirements (SR) and international

standards (IS) Other design aspects such as environmentalconsiderations operational models and architectural re-quirements are outside the scope of this work

e new QFD-based design is obtained through thefollowing steps

21 Step 1 Listing Stakeholder Requirements First of alla focus group of ED stakeholders in Egypt and Saudi Arabiaincluding patients was asked to mention those needs thatthey believe are important to improve the ED design e-ciency and patient satisfaction In addition other conceptson ED design were collected from the guidelines of theAustralasian College for Emergency Medicine [1] theAustralasian Health Facility Guidelines [2] ED patient owguidelines ([5 9]) and ED overcrowding reduction concepts[11] ese concepts were used along with the inputs of thefocus group to build a questionnaire of 84 items

en we classied the survey items into eight groupsnamely (1) basic services (2) requirements to streamline thematerial ow (3) requirements to streamline the patientow (4) clinical support services (5) consultation services(6) areas to support the diagnostic services (7) patientholding areas and (8) areas for stapound support and teaching

e survey was then conducted for two months among118 ED stakeholders all of whom at the time of the surveywere working in either Egypt or Saudi Arabia e stake-holders can be roughly divided into two main groups erst one includes strongly-aliated ED stapound (eg physiciansnurses administrators and technicians) whereas the secondgroup includes loosely-aliated professionals who do notwork inside the ED but are linked to it (eg clinical engi-neers healthcare planners pharmacists and non-EDphysicians)

Out of 118 subjects 108 completed the questionnairewith a response rate of 915e respondents were asked torate the questionnaire items based on a 5-point importancescale (0 not important 1 slightly important 2 moderately important 3 important and 4 extremelyimportant) en the average importance value of each itemwas calculated and converted into a percent score

(F)Technical targets

(A)

Custo

mer

nee

ds

(D)Relationship matrix

(C)Design specifications

(E)Roof

(B)

Plan

ning

mat

rix

Figure 1 e House of Quality













IRi Ti minusEi (1)


ndash3

1 9

3 3 90 1 3 9

1 3 3 3 3

1 1 1 1 1 1

0 1 3 3 1 0 1



11 9 0 X X 27 27 27 676 05






1004 Priorities 104 396 505 227 069 094 213 255 1863

100

14472428299

5 Weight 56 213 271 122 37 50 114 137

Targ

et (T

)

Dia

gnos

tic zo

ne

Supp

ort s

ervi

ces z

one

Exi

sting

spac

es (E

)


Administrative zone

Abso

lute

wei

ght (

AW)

1 AHFG




Diagnostic zone


Surgical zone

3 DoD

Trea

tmen

t and

ad

miss

ion

zone



Relat

ive w

eigh

t (R

W)

Adm

inist

rativ

e zon

e

Impr

ovem

ent r

atio

(IR)

Surg

ical

zone

2 NHS

Tem

pora

ry b

uffer

and

disc

harg

e zon

e

Initi

al ad

miss

ion

and

disa

ster m

anag

ing

zone

Patie

nt ar

rival

zone3 Design

specs








RWi AWi

1113936ni1AWi

lowast100 (3)



TPj 1113944nm





Wj TPj

1113936mj1TPj

(5)






















(6)







0

20

40

60

80

100

0 20 40 60 80 100

SR-E

D2

SR-ED1

y = 10183x ndash 003Rsup2 = 072p lt 0001






4 Conclusion



Data Availability








ndash500

50100150200

Diff

eren

ce ra

tio



Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(a)



ndash500

50100150200

Diff

eren

ce ra

tio


Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(b)



References



























RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia













IRi Ti minusEi (1)


ndash3

1 9

3 3 90 1 3 9

1 3 3 3 3

1 1 1 1 1 1

0 1 3 3 1 0 1



11 9 0 X X 27 27 27 676 05






1004 Priorities 104 396 505 227 069 094 213 255 1863

100

14472428299

5 Weight 56 213 271 122 37 50 114 137

Targ

et (T

)

Dia

gnos

tic zo

ne

Supp

ort s

ervi

ces z

one

Exi

sting

spac

es (E

)


Administrative zone

Abso

lute

wei

ght (

AW)

1 AHFG




Diagnostic zone


Surgical zone

3 DoD

Trea

tmen

t and

ad

miss

ion

zone



Relat

ive w

eigh

t (R

W)

Adm

inist

rativ

e zon

e

Impr

ovem

ent r

atio

(IR)

Surg

ical

zone

2 NHS

Tem

pora

ry b

uffer

and

disc

harg

e zon

e

Initi

al ad

miss

ion

and

disa

ster m

anag

ing

zone

Patie

nt ar

rival

zone3 Design

specs








RWi AWi

1113936ni1AWi

lowast100 (3)



TPj 1113944nm





Wj TPj

1113936mj1TPj

(5)






















(6)







0

20

40

60

80

100

0 20 40 60 80 100

SR-E

D2

SR-ED1

y = 10183x ndash 003Rsup2 = 072p lt 0001






4 Conclusion



Data Availability








ndash500

50100150200

Diff

eren

ce ra

tio



Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(a)



ndash500

50100150200

Diff

eren

ce ra

tio


Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(b)



References



























RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia






RWi AWi

1113936ni1AWi

lowast100 (3)



TPj 1113944nm





Wj TPj

1113936mj1TPj

(5)






















(6)







0

20

40

60

80

100

0 20 40 60 80 100

SR-E

D2

SR-ED1

y = 10183x ndash 003Rsup2 = 072p lt 0001






4 Conclusion



Data Availability








ndash500

50100150200

Diff

eren

ce ra

tio



Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(a)



ndash500

50100150200

Diff

eren

ce ra

tio


Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(b)



References



























RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia





(6)







0

20

40

60

80

100

0 20 40 60 80 100

SR-E

D2

SR-ED1

y = 10183x ndash 003Rsup2 = 072p lt 0001






4 Conclusion



Data Availability








ndash500

50100150200

Diff

eren

ce ra

tio



Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(a)



ndash500

50100150200

Diff

eren

ce ra

tio


Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(b)



References



























RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia



4 Conclusion



Data Availability








ndash500

50100150200

Diff

eren

ce ra

tio



Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(a)



ndash500

50100150200

Diff

eren

ce ra

tio


Initi

al ad

miss

ion

disa

ster

Patie

nt ar

rival

Trea

tmen

tadm

issio

n

Dia

gnos

is

Surg

ery

area

Buffe

rdi

scha

rge

Supp

ort s

ervi

ces

Adm

inist

ratio

n

(b)



References



























RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia


References



























RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia




RoboticsJournal of




VLSI Design



Shock and Vibration







Journal of



Volume 2018



Volume 2018


Journal of




SensorsJournal of



RotatingMachinery





Propagation






Hindawi


Advances in

Multimedia


functionalandspatialdesignofemergencydepartments...

Documents