healthcare ergonomics

8/8/2019 Healthcare Ergonomics

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Ergonomics forHealthcare Environments

Tim Springer, Ph.D.President

HERO, Inc.


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Table o Contents

Executive Summary 1

Ergonomics or Healthcare Environments 6

Introduction 6

I Background - Context 6

Rising Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Increased Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Building Boom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

War or Talent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Changing Nature o Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Industry Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Golden Opportunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

II Applying Ergonomics in Healthcare Environments 11

Unique Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

History & Tradition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Untapped Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Why is Ergonomics Important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Ergonomic Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Design Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Ergonomic Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

The Practice o Ergonomics: 17

Di erent Places - Di erent Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Conclusion

Annotated Bibliography & In ormation Resources 20

About the Author 37


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1Ergonomics or the Healthcare Environment

Executive Summary The healthcare industry aces a number o signi cant challenges:

Rising Costs Healthcare costs continue to rise aster than infation. Consequently, increasing attention is ocused on how healthcareorganizations operate. Management is looking or ways to economize through cost savings and cost cutting.

Increased Demand Demand or healthcare will grow, at least through 2030-2050 due to population growth, immigration, population shi ts,and increasing expectations and demands o aging Baby Boomers

Building Boom In response to increased demand, the US is experiencing a huge hospital building boom.Over the next ten years $200 billion dollars will be spent on hospital construction.

War for Talent In the ace o increased demand and an unprecedented building boom, hospitals and healthcare organizations acesigni cant sta ng shortages. Issues o recruiting, retention and turn-over are critical to the survival and success o anyhealthcare organization.

In addition to these orces or change in healthcare, there are changes and trends within the industry:

Changing Nature of Work Regulations (HIIPA, Medicare Plus Choice), technology and changing work styles (multidisciplinary teams) are exertingpro ound e ects on healthcare.

Industry Trends

1. Evidence-based practice. Applying this concept to the development and provision o healthcare environmentshas lead to evidence-based design. Research cited in this white paper speaks to the value o applyingergonomics to the design o healthcare work environments.

2. Focus on the patient experience. Representing a shi t rom provider ocus to patient ocus, this trend hasraised the issue o environmental quality or both patients and sta .

Healthcare is ocusing on the physical environment as a health and healing tool and as an asset to be managed. Twoorganizations - Center or Healthcare Design (CHD) and Planetree are dedicated to ostering evidence-based design o healthcare environments.

Taken together, the above conditions represent a golden opportunity to introduce ergonomic concepts andprinciples to the design and confguration o healthcare environments

Knoll, Inc. 2007


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When Applying Ergonomics to Healthcare Environments several unique characteristics distinguish them fromother types o workplaces:

Unique Setting

Healthcare presents a unique combination o challenges and opportunities or applying ergonomics.

Nonstop operation - 24/7/365 means shift work and shared workplaces.

Healthcare must serve entire population

Regulations and information security requirements impose unique and potentially con icting demands on workplace

Nearly the complete range of physical actions performed from less than ideal positions and postures increase risk o injury.

Many healthcare jobs involve multi-tasking with physical activity and highly skilled knowledge work and technology use.

Predominantly female workforce

History & Tradition

A long history o looking or ways to improve the working environment; however the primary ocus has been on the patientand sta -patient interactions. (e.g. adjustable beds)

Untapped Potential

Sta workplaces not involving direct patient contact have not bene ted rom applying ergonomics. Potential is ound inthree primary areas:

1 Market di erentiation

a. In a war or talent, workplace makes a di erence.

b. Culture image and identity are refected in the physical environment

c. The workplace is a strategic asset

2 Per ormance Per ormance improved 17.7% while the bene t-to-cost ratio was 24:1

a. Increase Sta E ectiveness, Reduce Errors, and Increase Sta Satis action

b. Improve patient sa ety

c. Reduce stress and improve outcomes

d. Improve overall healthcare quality

3 Health & Sa ety

a. MSD injuries are very expensive

b. Carpal Tunnel can be reduced or alleviated

Why is Ergonomics Important?

The goal o ergonomics is to support people in what they do or work so that they are sa e, com ortable and productive. The primary ocus is on people and the tools and technology they use.

Ergonomics focuses on people

Good ergonomics yields improved performance and productivity

Good ergonomic programs include training and change management

Good ergonomics programs always yield more bene ts and save more money than they cost


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Ergonomic Fundamentals

Ergonomics approaches design tries to address unctional requirements o people at work by asking six basic questions:

Who are the users?

What do workers do?

How do workers perform their job?

When do workers engage in speci c work behaviors?Where do workers engage in tasks?

Why do workers do what they do in the way that they do it?

Design Approaches

Ergonomics employs three undamental approaches to design to accommodate individual di erences whilesimultaneously meeting the needs o the population o users.

Design for the extreme

Design for the average

Design for the adjustable range

Ergonomic Strategies

Adapt the workplace to the worker

Support work in the way it is done

Optimize support for the primary task

Provide appropriate user control

Emphasize ease of use

Provide for Personalization of Space

Train people in the proper use of equipment

The Practice o Ergonomics

When applying ergonomics, one considers the nature o the workers, the work they per orm and the workplaces.Functional requirements tend to cluster into one o three workplace types: Dedicated or solo workplaces, sharedworkplaces and collaboration workplaces:

Dedicated Workplaces

Used primarily by only one person

Designed or adapted to the needs of a speci c user.

Primary tasks are typically:

- Seated

- Solo, heads down

Minimize distractions


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Dedicated Workplaces - Examples

Executives & Administrators

Patient facing

Registration & Admitting

Specialty

Diagnostic imaging Physicians of ces

Back of ce support personnel

- Health records

- Quality Control

- Accounting

Dedicated Workplace Considerations

Appropriately adaptable workplaces

Work surface heights set at appropriate level for speci c user st time of set-up. (may trade ease o adjustment or cost)

Task seating

Support the position in which primary task is performed

User adjustable

Task lighting

Suf cient storage

- Hot les and project work within reach

- Archive everything else o site

Space for two or more for collaboration

Shared Places

Used by multiple people during a shift and throughout a 24 hour period Often multiple tasks including:

Heads down concentration

Communication & collaboration

Multi-tasking

Maximize adaptability and exibility

Shared Workplaces - Examples

Nurses station

Patient rooms

Registration Labs

Pharmacy


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Shared Workplace Considerations

Support both sitting and standing work as appropriate

Maximize adjustability to accommodate multiple users

Ease of use of any adjustments is essential

Support multi-tasking

- Solo, heads down- Collaboration

Suppor t variety of work styles

Collaboration Places

Used concurrently by two or more people

Support team work and communication

Minimize distraction to users and others

Support both formal and informal communication

Collaboration Workplaces - Examples

Meeting rooms

Training rooms

Of ces

Hallways

Nurses stations

Cafeteria/lunch rooms

Break rooms

Collaboration Workplace Considerations

Comfort

- Variety o users

- Length of use (minutes to hours)

Duration

Information sharing

Display

Distraction

- To others

- To users

Conclusion

Healthcare environments possess signi cant untapped potential or bene ts to organizations willing to apply ergonomicsto sta workplaces. Evidence supports investing in workplace ergonomics to realize improved per ormance, improvedworker satis action, positive a ect on recruiting and retention and improved quality o patient care.


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Ergonomics or Healthcare Environments

Introduction

Healthcare as an industry and as a work environment presents a unique set o circumstances, opportunities andchallenges or applying ergonomics. This report is intended to work as a companion piece to the PowerPoint presentation

o the same name. In it you will nd background, research, re erences and discussion o the issues surrounding theapplication o ergonomics to healthcare environments.

I Background - Context

Healthcare is the largest industry in the American economy:

Healthcare provided 13.5 million jobs in 2004

Eight (8) out of 20 occupations projected to grow the fastest are in healthcare.

More new wage and salary jobs created between 2004 and 2014 will be in healthcare than in any other industryabout 19 percent, or 3.6 million.

Rising Costs

Healthcare spending in the U.S. continues to rise at the astest rate in history. Total national health expenditures or 2005(the last year or which data are available) rose 6.9 percent two times the rate o infation. Total spending was $2 Trillion in2005, or $6,700 per person. Total healthcare spending represented 16 percent o the gross domestic product (GDP).

U.S. healthcare spending is expected to increase at similar levels or the next decade reaching $4 Trillion in 2015, or 20percent o GDP.

For perspective, healthcare spending in the U.S. is 4.3 times the amount spent on national de ense.

Consequently, Healthcare as an industry is under intense pressure to control costs, economize, stream-line and seek bestpractices to increase e ciency and e ectiveness. Appropriate application o ergonomics to healthcare workplaces o ersone tool to meet those goals.

Increased Demand

The demand or healthcare is high and will continue to increase. Several actors are ueling the demand - population shi tsin the United States, the graying o the baby boom generation, and the introduction o new technologies. Consider the

ollowing:

The population of the U.S. is projected to grow 18% from 2000 to 2020.

Population growth is driven by fertility, mortality, and net immigration. Population growth should continue throu2030 and then slowly begin to decline.

Immigration and higher birth rates among ethnic groups means greater cultural and ethnic diversity.

Aging population. The elderly (age 65 and over) currently represent 13 percent of the U.S. population. That propis expected to rise to 17 percent by 2020. By 2020 almost 40 percent of a physicians time will be spent treatelderly.

Retirement among Baby Boomers will increase the population shift to warmer climes (i.e., Sun Belt states).

Increasingly af uent and demanding consumers (Baby Boomers) will remain more active as they age and expectspecial treatment.

Improved medical technology and procedures will yield longer life spans, greater demands for state of the art anincreased demands on HealthCare.


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Building Boom

The United States is acing one o the largest hospital building booms in history. Nationwide, more than $16 billion wasspent or hospital construction in 2004. Spending will rise to more than $20 billion per year by the end o the decade. Overthe next ten years at estimated $200 billion will be spent on new construction. These hospita ls will remain in place ordecades.

War for Talent

In the ace o this increased demand and new building boom, healthcare organizations are locked in an increasingly ercecompetition or quali ed employees. This War or talent is driven by:

Staf ng shortfalls

Recruiting costs and practices

Turnover

Sta fng Short alls

Healthcare organizations in the US and worldwide ace signi cant sta ng short alls. Data rom the US Department o Health and Human Services project the ollowing short alls:

Posi t ion 2005 201 0 2020

Nurses 126000 275000 800000

Pharmacists 10000

Lab Tech 13000

Imaging Tech 13000 75000 75000

Source: USDHHS

A study sponsored by the American Hospital Association shows a consistent trend in sta ng vacancies across all typeso healthcare work.

Pos i t ion Mean Vac ancy Rate

Registered Nurses 13.0%

Pharmacists 12.7%

Housekeeping/Maintenance 5.3%

IT Technologists 5.7%

Billers/Coders 8.5%

Laboratory Technicians 9.5%

Nursing Assistants 12.0%

Licensed Practical Nurses 12.9%

Imaging Technicians 15.3%


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Recruiting Costs and Practices

The circumstances refected by these data has helped uel competition or quali ed healthcare pro essionals. As a result,costs associated with nding and hiring sta , especially nurses, has risen 50-75% . According to the Harvard BusinessSchool, the cost of hiring an unsuitable person can be two times the employees annual compensation, includingexpenses, training, bene ts, wages, commissions, and bonuses. That means, or example, that having to terminate anewly hired $60,000-per-year employee can cost an organization more than $120,000 in both direct and indirect costs.Consequently it is not surprising to nd organizations o ering incentives to recruits and bonuses or those who can ndand recommend quali ed candidates. One example is a program at Duke University Medical System that pays $5000 orre errals that are hired.

Historically, US healthcare organizations have looked to imported talent to help meet sta ng short alls and help containpersonnel costs. The Philippines has been the primary source o oreign nurses and sta . However, global competition has

orced the US organizations to broaden where they look or talent to include South A rica, The Mediterranean, The MiddleEast and Eastern Europe adding cultural and ethnic diversity to the healthcare work environment.

Turnover

Sta turnover is a signi cant issue or healthcare leaders due to the shrinking work orce in Western countries and anincreased demand for healthcare services as the population ages. Nurse turnover is typically highest on medical/surgiunits, compromising quality and increasing cost. Sta shortages and high turnover are o ten associated with registerednurses, but also a ect other pro essions such as imaging technicians, pharmacists, and lab technicians. Both shortagesand high turnover place additional stress and strain on remaining sta , eroding continuity o care and creating unwantedexpense

The economic impact o turnover is signi cant:

1. Recruitment o replacements, including administrative expenses, advertising, screening and inter-viewing,and services associated with selection, such as security checks, processing o re erences, and, possibly,psychological testing.

2. Administrative hiring costs.

3.Lost productivity associated with the interim period before a replacement can be placed on the job.

4.Lost productivity due to the time required for a new worker to get up to speed on the job.

5.Lost productivity associated with the time that coworkers must spend away from their work to help a new worker.

6. Costs o training, including supervisory and coworker time spent in ormal training, as well as the time that theworker in training must spend o the job.

7. Costs associated with the period prior to voluntary termination when workers tend to be less productive.

8.In some cases costs associated with the communication of proprietary trade secrets, procedures, and skillscompetitive organizations.

9. Public relations costs associated with having a large number o voluntary or involuntary terminations in thecommunity spreading gossip about the organization.

10. Increased unemployment insurance costs.

Example

The cost of replacing 288 employees per year (in a hospital with 200 beds employing 1200 persons with a turnovof 2% per month) was $2,888,295.52 when all sources of costs were analyzed.

The American Hospital Association estimates the cost o replacing one sta nurse equals the annual salary or that nurse.

Why do some people leave their jobs while others stay? Research suggests a causal chain in which perceivedautonomy, job satis action, intent to leave the hospital and turnover are the sequence o outcomes.


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Reasons People Leave

1. Bad management, supervisor or team leader

2. Many healthcare workers are disenchanted with their pro ession and eel undervalued

Reasons People Stay

Exciting work

Career growth

Working with great people

Fair pay

Space (both personal and physical)

Changing Nature of Work

The organization and delivery o healthcare in the United States is undergoing signi cant social, organizational, economic,political, and cultural changes with important implications or the uture o medicine as a pro ession. In part due toincreased demand and rising costs, healthcare is under more regulatory pressure than almost any other industry.

Examples

HIPPA (Health Insurance Portability and Accountability Act) & information security

Medicare Plus Choice

HIPPA exerts far-reaching effect since sharing information regarding a patients condition and treatment are fundameto e ective, team-based healthcare. The workplace can play a major role either helping or hindering healthcarepro essionals collaborate while complying with in ormation security requirements o HIPPA.

Healthcare has a long history o applying technology to advance the practice o medicine. However, rapid advancesin in ormation technology are changing all aspects o work rom decision support to in- ormation management topatient care

Examples

Electronic medical records (EMR) software

Electronic medication management Computer aided imaging

Remote collaboration

Robotics - from surgery to consultation

PCs to laptops to handhelds & PDAs

Here too, the workplace can play a pivotal role in helping healthcare sta maximize the bene ts o technology whileminimizing the potential risks o its use.

Finally, healthcare work is exploring and evolving new approaches to care. The nature o how healthcare is applied andadministered is constantly changing

Examples

Interdisciplinary team work Prevention and holistic approaches


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Industry Trends

Two key industry initiatives are beginning to change the way hospitals operate and especially how they view the physicalenvironment:

Evidence-based practice This initiative o the US Government, Department o Health and Human Services, Agencyor Healthcare Research and Quality. (AHRQ) began in 1997. AHRQ launched a program to promote evidence-based

practice in everyday care by establishing 12 Evidence-based Practice Centers (EPCs). The EPCs develop evidence

reports and technology assessments on topics relevant to clinical, social science/behavioral, economic, and otherhealthcare organization and delivery issuesspeci cally those that are common, expensive, and/or signi cant for thMedicare and Medicaid populations.

Focus on the patient experience Representing a the shi t rom provider ocus to patient ocus, organizations aretracking outcomes including: improved ood service; reducing the length o hospital stays; reducing or eliminatinginfections; a more holistic approach to healing; a focus on the physical environment; and including a patients faand support network in healthcare decisions.

Hospitals are beginning to focus on the physical environment as a tool in health and healing - not only for patientsbut also or healthcare workers. The Center or Healthcare Design (CHD) and Planetree are two organizations dedicated to

ostering evidence-based design and a more comprehensive approach to healthcare environments.

CHD launched its Pebble Project, to measure the e ects o the built environment. The project also aimed to create a ripplee ect o sharing documented examples o healthcare acilities in which design has improved quality o care and nancialper ormance o the institution. Pebble Project partners are demonstrating that acility design can:

Improve the quality of care for patients

Attract more patients

Recruit and retain staff

Increase philanthropic, community, and corporate support

Enhance operational ef ciency and productivity

Planetree is a nonpro t membership organization founded in 1978. Planetree works with hospitals and health centersto develop and implement patient-centered care in healing environments. One o the core competencies o Planetree is

Architectural and Interior Design Conducive to Health & Healing:

Planetree rmly believes that the physical environment is vital to the healing process o the patient. Facility designshould include e cient layouts which support patient dignity and personhood. Domestic aesthetics, art and warmhome-like, non-institutional designs which value humans, not just technology, are emphasized. Architectural barrierswhich inhibit patient control and privacy as well as inter ere with amily participation are re-moved. Awareness o thesymbolic messages communicated by design is essential.

Designing and maintaining an uncluttered environment encourages patient mobility and a sense of safe shelter. Tdesign o a Planetree acility provides patients and amilies with spaces or both solitude and social activities, andincludes libraries, kitchens, lounges, activity rooms, chapels, and gardens. Com ortable space and accommodationsare provided or amilies to stay overnight. Healing gardens, ountains, sh tanks and water alls are provided to connectpatients, amilies and sta with the relaxing, invigorating, healing, and meditative aspects o nature.

It is just as essential (emphasis added) to create healing environments or the sta as it is or patients. Physicians,nurses and ancillary sta are very much a ected by their working environment. It is very hard to help patients heal andrecover in inhospitable, cold and impersonal spaces. Lounges and sacred space for staff are an important componenin the creation o a healing environment.


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History & Tradition

The concepts o ergonomics are not new to healthcare. Making the things people use and how and where they use themas sa e, easy to use, com ortable and e ective as possible parallel the goals and objectives o e ective healthcare.

Medicine and Healthcare have a long tradition o attention to the importance o the physical environment and developingand using devices and techniques that refect ergonomic ideas and principles. One o the earliest proponents o thisnotion was Florence Nightingale. Her e orts on behal o the British soldiers during the Crimean War ocused on design

engineering to improve lighting (especially with sunlight), ventilation, heating and cooling, sewerage acilities, and su cientspace for soldiers personal belongings. Since then, environmental factors such as noise, air quality, light, toxic exposutemperature humidity, and aesthetics have been scrutinized or their e ects on both patients and workers.

In todays modern hospital, ergonomics is an accepted part of much of the patient care setting. Devices such as adjuhospital beds are accepted and expected as standard equipment.

Recently, hospitals have begun to address risks associated with moving patients. A rise in obesity (bariatric patients),sta ng shortages and an aging healthcare work orce has increased concern regarding accidents and injuries associatedwith patient transport. Many organizations employ li ting teams and Zero-li t policies while moving patients. Theseapproaches rely on technology and devices to relieve or eliminate the stress and strain o physical li ting that can leadto injuries. Recognizing the potential risks associates with patient transport, a national movement is underway to passsa e patient handling no manual li t laws at both state and national levels. These laws would require mechanical li tingequipment and riction-reducing devices or all healthcare workers, patients, and residents across all healthcare settings.

These examples illustrate the historic and traditional approach o healthcare when applying ergonomics a ocus on

patients and patient-sta interactions.

Untapped Potential

The workplace represents an area o substantial untapped potential to yield bene ts to healthcare organizations byapplying ergonomics in three principle areas:

1.Market Differentiation As discussed above, healthcare organizations are engaged in a war or talent caused by sta ng short alls, risingrecruiting costs, and increased turnover. The way to win the war or talent is by attracting and retaining the bestemployees. An e ective and underutilized tool in this war or talent is the workplace.

The physical workplace is the single most visible manifestation of an organizations culture, image and identity. Tnature o the workplace states in loud, clear, nonverbal terms, how an organization values its employees and how itcommunicates its values.

The importance o high-per orming healthcare environments is recognized by the Baldrige National QualityProgram: Organizations with high levels o work orce engagement are o ten characterized by high-per orming workenvironments. Research has indicated that engagement is characterized by per orming meaning ul work; havingorganizational direction, per ormance accountability, and an e cient work environment.

Few hospitals and healthcare organizations actively employ the power o the physical workplace as a marketdi erentiator in the competition to attract and retain the best employees. Research results support investing in thephysical workplace pays dividends through higher per ormance levels, greater job satis action and improved patientsatisfaction. Researchers also identi ed the built environments role as a moderating variable that can lead to impprocesses and outcomes.


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2 Per ormanceHealthcare pro essionals are under increasing pressure to work more e ciently with ewer resources. This stress ulsituation can be made worse by physical discom orts in the workplace.

In a review o relevant literature, Ulrich & Zimring (2004, 2006) ound scienti c evidence linking the physical environmentto per ormance in the ollowing areas:

1. Increase Sta E ectiveness, Reduce Errors, and Increase Sta Satis action by Designing Better Workplaces

(emphasis added)Improve Staff Health and Safety through Environmental Measures (e.g. In-door air quality, thermal environment)

2. Improve patient sa ety

Reduced staff fatigue

3. Reduce stress and improve outcomes

Reduce Noise. Studies have shown that noisy environments contribute to the perception ofincreased work demands, stress, and burnout. Not surprisingly, high noise levels can also in-creasethe risk o errors when sta are per orming critical tasks such as dispensing medical prescriptions,and can even inter ere with patient healing and recovery. They can also put patient con dentialityat risk, as sta s are orced to speak more loudly to communicate vital health in ormation. A quieteratmosphere can also create a more nurturing, healing environment or patients and sta alike.

Reduce Spatial Disorientation (way nding)4. Improve overall healthcare quality

Adapting workplaces to t workers and the work they per orm is a undamental principle o ergonomics. Highlysupportive workplaces - those that are designed to optimize per ormance o the tasks and support the work behaviorso sta - are also high per ormance workplaces.

While cost control is critical in todays healthcare industry, organizations rarely recognize the workplace as an asserom which one can expect a return on investment. Evidence suggests spending on workplaces to improve worker

per ormance, satis action and retention is a small, but highly leveraged investment. In other words, the relatively smallexpense o workplace can yield substantial returns by improving the per ormance o the comparatively large investmentin personnel.

Example

Amick and colleagues (2002) showed that attention to ergonomics in healthcare workplaces provides a cost-e ectiveway to improve per ormance and productivity. Per ormance increased 17.7% while the bene t-to-cost ratio was 24:1.

3. Health and Safety of Workers Healthcare has recognized the potential risk or injuries caused by li ting - especially li ting associated with patienttransport.(see zero li t above). The National Institute o Occupational Sa ety & Health (NIOSH) tracks the economica ect o back injuries and the associated medical, worker compensation and lost time associated with them:

Back-related injuries cost $52 Billion in direct medical and lost time expenses.

Musculoskeletal Disorders (MSD) result in 16 Million lost workdays ($50 Billion) per year.

30% of all workers compensation claims are MSD costing $18 Billion per year.

The average MSD claim is over $18,000.

Carpal Tunnel surgery is now among the most frequently performed procedures in the US average cos

$50,000 per wrist.Sources: US Bureau of Labor Statistics & NIO

The untapped potential or ergonomics in healthcare is addressing musculoskeletal disorders (MSD) that a ectactivities beyond patient transport. Improperly or inappropriately adjusted and con gured workplaces contributeto MSDs such as those associated with computer use (e.g. carpal tunnel syndrome) and constrained postures(neck, shoulder, leg and back problems). Ergonomics can reduce the incidence and costs associated with thesehealth and sa ety issues.


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Why is Ergonomics Important?

It seems obvious that people pre er workplaces that are more com ortable, sa e, simple and easy to use, healthy andproductive but it requires both science and art to achieve that the science and art o ergonomic design.

Ergonomics focuses on people - the single largest and most valuable asset of any organization. Regardless ofappearances, people are di erent rom one another. Ergonomics recognizes and strives to accommodate individualdi erences in everything rom size to skills, rom work styles to idiosyncrasies.

Good ergonomics yields improved performance and productivity. Research evidence over the past 25 yearsconsistently shows an average o 12% improvement in per ormance when a comprehensive approach to ergonomicsis applied to workplaces . Comprehensive ergonomics means looking at the total workplace rom task design andwork behaviors, to tools and technology to visual, auditory, thermal, air quality and spatial environmental variables.

Good ergonomic programs include training and change management. Ergonomics may seem intuitive - but peopleneed to be shown how to use eatures and understand how some behaviors increase risk o injury. Also, changing apersons environment can profoundly affect their behavior. So, to minimize negative affect and maximize acceptanand positive a ect, communication and change management are essential.

Good ergonomics programs always yield more bene ts and save more money than they cost.

Ergonomic Fundamentals

Ergonomics addresses the unctional requirements o people at work by asking six basic questions: who, what, how, when,

where and why?

Who are the users?Ergonomics begins by understanding the characteristics o the population o users. The challenge is to developsolutions that accommodate individual di erences while accommodating everyone who will use the designed productor environment. Physical measures o people, such as standing height, hip circum erence or knee height when seated,are called anthropometrics. These measures are important when designing things or people to use. The assumptionis that measures o the entire population assume a normal distribution that is shown graphically by a bell shapedcurve. The nature o anthropometric data and the normal distribution allows ergonomists to determine who among thepopulation will be accommodated by a particular design decisions. How this is used is discussed below.

What do workers do? It is important to understand the activities that comprise the tasks and jobs workers per orm. Task analysis allowsergonomists to understand the work behaviors and unctional requirements o a set o tasks or a job amily.

How do workers per orm their job? Are there particular work styles or sequences o activities that characterized a speci c job or group o workers? Thisunderstanding in orms unctional design speci cations that support work in the way it is done.

When do workers engage in specifc work behaviors?Sequence and duration o work activities helps determine levels o importance. There is a notable trade-o betweentime on task and accommodation or com ort. Generally, it is more important to support activities and work behaviorsthat constitute the majority of a persons day - what might be called their primary tasks. If a person spends 15minutes at a particular workplace, they can tolerate a solution that is more generic and potentially less com ortable,than i they are engaged in intensive concentrated work or two to our hours. However, priorities and solutions mustbe weighted by other in ormation relating to importance. For example, in healthcare a code signi es a specialevent o critical importance (like heart ailure) that may be in requent. Under such special circumstance the criticalimportance o the out-come requires the best support or workers per orming that job unction at that time.

Where do workers engage in tasks? The characteristics o location and con guration o workplace helps determine how best to support the necessarywork behaviors and unctions. Workplaces tend to all into one o three categories: solo or dedicated workplaces,shared workplaces, and collaborative workplaces. Each have di erent purposes and unctional requirements. Thus,each workplace type has corresponding ergonomic considerations.


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Why do workers do what they do in the way that they do it? Are their policies, procedures or practice guidelines or requirements that infuence why workers per orm their assignedtasks in a certain order or ashion? Routine, peer suggestions, and superstitious behavior may also play a role in whywork is per ormed in a certain way.

Understanding the nature o the workers, work and workplace enables ergonomic experts to apply the appropriate designapproach.

Design Approaches

Ergonomics employs three undamental approaches to design to accommodate individual di erences while simultaneouslymeeting the needs o the larger population o users. To understand the di erences in these approaches and why each isappropriate or particular settings, consider the bell shaped curve shown below:

Notice a ew important characteristics o the distribution represented by this graph. The highest point o the curve is in thecenter and represents the average or mean. In this case, the mean is the exact middle o the distribution - the median. Thushal the population alls on either side o both the average (mean) and the median. The ends o the curve are called theextremes. Looking at either end of the curve, one sees small percentage gures (2.14%; 0.13%). These are the perceo the population that alls between that point and the nearest end. The numbers along the baseline (-4 to +4) arestandard deviations (sd). So, the area under the curve rom -2 to +2 includes approximately 95% o the population.

Using these characteristics o the normal distribution, ergonomics has developed three approaches to design:

Design for the Extreme This approach is used where accommodating the largest or smallest individuals will also serve the needs o therest o the population. For example, doorways are designed so the tallest person can walk through them - as wellas the rest o the population.

Design for the Average Where a large portion o the population will use the same device or environment, design or the average may bemost appropriate. It is used in circumstances where duration o use or cost precludes designing in adjustments.Examples include grocery store checkout aisles and o ce reception counters.

Design for the Adjustable Range This approach is used to maximize goodness o t where the device or environment adapts to the user. Acommon example is automobile driver seats with 6 or 8 way adjustments to meet the full range of the uspopulation. Similarly most modern o ce chairs employ this design approach and provide several axes o

adjustment to accommodate a wide range o users.


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Ergonomic Strategies

Adapt the workplace to the worker - not vice versa. People are very adaptive. They can accommodate poor desiand hostile environments. But adaptation takes its toll on users, requiring energy to adapt. Adapting to poor design orenvironmental elements leads to de-creased per ormance and atigue. Fatigue leads to errors, accidents and injury.

Appropriately adaptive equipment and environments relieve strain on the worker to adapt to short-comings in theworkspace. Provide adjustable urni ture and equipment to support the wide range o sizes and shapes o people inthe work orce.

Support work in the way it is done. Appropriate support of work styles and practices should be provided. Forexample, i people pre er storing paper in ormation in piles, expecting in ormation to be stored in drawers or binsworks against the way work is done. Providing o horizontal sur aces and shelves or storage supports the inherentwork behaviors. Similarly, multiple users assuming multiple positions and postures require easily moveable andadjustable support sur aces.

Optimize support for the primary task. Work surfaces that are solid and large enough to sup-port the primary tarequired.

Provide appropriate user control. Control over their workplace is important to workers sense of satisfaction andper ormance. Adjustments must be simple and easy to per orm. Some workplace adjustments may be made at thetime o setup; however important adjustments like seat position should be user controlled.

Emphasize ease of use. Adjustments, control motions, connects and disconnects should be easy to use. Forexample, controls (e.g., seat adjustments) should be easy to reach, easy to operate and should be either clearly

labeled or communicate unction by shape or motion. Access to power, net-work, and telecommunication portsshould be at desk height or belt-line level, not where access re-quires stooping, bending or crawling under worksur aces.

Provide for Personalization of Space. Accessories that complement, as opposed to supplant, the function of theworkplace allow the user to ne tune their workspace to meet their individual pre erences.

Train people in the proper use of equipment. Good design is not enough. Ergonomics may seem intuitive - butstill need to be shown how to use eatures and understand how some behaviors increases risk o injury. Trainingthat demonstrates the technique and bene ts o appropriate adjustments are required. The best workplace is onlye ective i people know how and why to use it.


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The Practice o Ergonomics

Different Places - Different Needs

When examining work behaviors, unctional requirements tend to cluster into one o three workplace types: Dedicated orsolo workplaces; shared workplaces; and collaborative work-places.

Dedicated Workplaces

As the name implies, these places are used primarily by one speci c person. They are, in e ect, a home base.Consequently, they should be designed or adapted to meet the needs o the primary user. Typically, dedicated spaces areused or tasks that involve a high level o concentration - what is re erred to as heads down work, or a high level o privacyor in ormation security. To provide the best support or concentration, it is advisable to use environmental elements, suchas partitions, sound absorption or sound masking, to minimize distractions o workers per orming their jobs in dedicatedplaces.

The primary tasks are usually per ormed solo and in a seated position. However, dedicated places can also be used orconsultation and other unctions, as noted below - but the primary unction is or solo, heads down work.

Dedicated Workplaces - Examples

Examples o dedicated workplaces are ound in most organizations. The most common are private

o ces or Executives and Administrators. In healthcare, particularly with in ormation security concerns associatedwith HIPPA, one might also nd a need or dedicated workplaces among patient acing tasks such as Admitting andRegistration as well as back of ce sup-port jobs such as Patient Health Records and Accounting. Similarly, Physo ces also re-quire a level o privacy and in ormation security associated with dedicated workplaces.

Finally, one can nd unctional requirements or dedicated workplaces throughout and organization. One exampleis diagnostic imaging where advances in digital imaging technology have changed the nature o the tasks and thefunctional requirements. In todays diagnostic imaging workplace, it is common to nd the need for dedicated, lodistraction workplaces.

Dedicated Workplace Considerations

In keeping with the global ergonomic strategies, dedicated workplace should be appropriately adaptive. Since theworkplace should be designed and adapted to a speci c, primary end user, it may be possible to set such things asworksur ace height at the appropriate level during construction or set up o the workplace. Doing so may trade ease o adjustment or cost; however i done correctly, the worksur ace should t the worker.

Because most solo, heads down work is done rom a seated position, it is essential that dedicated workplaces areequipped with user adjustable task seating. Good task seating should do our things:

1. Support the body anatomically. Our bodies are round and curved, Task seating should be curved to t theshape o our bodies - not angled and sharp edged.

2. Provide a stable plat orm rom which to work. Adjustments o ten translate into sur aces and elements thatmove. Good ergonomic task seating should allow the worker to eel secure and not concerned that the chairmight move unexpectedly or unnecessarily.

3. Support work in the way it is per ormed. People come in a wide range o shapes and sizes. They also adopt a wide range o postures and positions to do their jobs. O ten they will change positionsthroughout the day. There is no one right way to sit, so good task seating should be adaptable to workposture and position.

4. Be easy to use - by the user. Adjustments should not require tools or manuals to per orm.If adjustments are easy to use - they wont get used. The result may constrained postures and higher risk o discom ort and injury.

Dedicated workplaces should have good uni orm lighting supplemented by user con-trolled task lighting. Again, peopleexhibit a wide range o visual acuity and ability to see under di erent lighting conditions. As we age we need more lightto see as well as when we were younger. All o which point to the need or user control over light alling on the primarytask space.


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Because dedicated workplaces are home base or their occupants, storage becomes a major concern. Mike Brill,the late head o BOSTI, once remarked, Everybody needs a place to keep their stu . With regard to dedicatedworkplaces, this means providing su cient work sur ace space or hot les - those documents and work product onwhich people are currently working. These materials should be within easy reach. To minimize space requirements anddiscourage pack rat behavior, the amount o le drawer storage should be kept to a minimum. A good archive system,where records can be retrieved within twenty- our hours will allow everything but the most current in ormation to be kepto -site.

Finally, dedicated workplaces are also o ten used as meting places (see collaborative spaces below). Consequently, it isadvisable to include su cient space and seating or at least one person other than the primary user.

Shared Places

Because healthcare operates around the clock, many places must be shared. Whether shared by workers on di erent shi tsor by several people during the shi t, sharing is something that is much more common in healthcare environments than otherindustries.

O ten the shared places must support a variety o behaviors and multiple tasks including the solo, heads down worktypically ound in dedicated places, as well as collaboration and communication.

Consequently, shared places o er an opportunity to exercise appropriate adaptability and fexibility through the applicationo one or more o the design approaches discussed above.

Shared Workplaces - Examples

The most common and obvious shared workplace in healthcare environments is a nurses station on a hospital foor. These workplaces must accommodate a wide range o di erent people over both a short period o time and within anygiven twenty- our hour period.

Similarly, patient rooms quali y as shared workplaces since many people rom nurses and technicians to physicians tovolunteers work with patients in these spaces, occasionally at the same time.

Other common shared spaces include laboratory and pharmacy workplaces as well as registration and admitting.

Shared Workplaces - Considerations

Because shared workplaces must accommodate the widest range o uses and users, they must exhibit a wide rangeo adjustments and fexibility or ability to be recon gured. As discussed in regard to task seating, adjustments must beusers controlled and easy to use.

Shared workplaces should support both sitting and standing work postures as appropriate. The requency and durationo use o shared workplaces necessitates the ability to quickly and easily change. Similarly, shared workplaces mustsupport multi-tasking, since both solo, heads down work and collaboration and communication occur there.

Finally, in addition to supporting the variety o users and tasks, shared workplaces should accommodate di erences inwork styles. People per orm the same jobs in a variety o ways. That may mean di erences in how they handle hot lesor di erences such as sitting or standing to do the same task. Whatever the di erence in work, worker or work style,good ergonomics will accommodate those di erences with adjustments that are quick, secure and easy to use.

Collaboration Places

Collaboration is essential to the practice o medicine and the delivery o e ective healthcare. Collaboration happenseverywhere in healthcare environments. But recent concerns and regulations regarding in ormation security and patienthealth records (e.g. HIPPA) will a ect the ways and places collaboration occurs. The design and con guration o healthcare

workplaces should support and acilitate collaboration while meeting both the letter and spirit o the in ormation securityregulations.

Collaboration places are used concurrently by two or more people. Because collaboration is at the heart o teamwork,such places should support not only verbal communication, but also in ormation sharing and display. Collaboration placesshould also sup-port episodes o activity where team members work independently in close proximity to one another. Thenature o communication associated with collaboration can be ormal (e.g., scheduled interaction with agendas) or in ormal(e.g., chance encounters or interrupt driven interactions).

By its nature, collaboration can be distracting to those not directly involved. Consequently, attention should be paid to howcollaboration places a ect and are a ected by proximity to others.


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Collaboration Workplaces - ExamplesThe most common orm o collaboration workplaces are meeting rooms. These collaboration workplaces best support

ormal interactions - usually involving a schedule, an agenda and a known list o participants. Similarly, other workplaceshelp support ormal collaboration, such as o ces with small con erence tables and training rooms. However, a greatdeal o collaboration inherent to healthcare is event driven, in ormal, and unscheduled. In ormal collaboration relies onserendipity and opportunity (e.g., seeing a person who can help). Thus many other places in healthcare environmentsquali y as collaboration workplaces. Examples include hallways, nurses stations, break rooms, ca eterias, lunch rooms,patient rooms, as well as more traditional meeting rooms and o ces.

Collaboration Workplaces - Considerations

Formal collaboration tends to have more structured requirements. Formal meeting spaces, whether meeting rooms,break rooms, or training rooms, should support many di erent users in a seated position. Com ortable, easily adjustedchairs and meeting tables will help support the variety o users and the range o duration and requency o user or theseworkplaces.

Sharing in ormation in a variety o orms and ormats is undamental to collaboration. Thus ormal collaborationworkplaces should include display walls (e.g., writable and tack-able sur aces) and electronic displays (e.g. computerprojectors). Increasingly, collaboration can occur remotely using technology. Thus some ormal collaboration workplacesshould support telecon erencing, either by telephone, computer or video link.

For short duration, in ormal interactions, the primary requirement is e ective communication. Thus, it may be

appropriate to support standing postures and ocus on the auditory and visual elements o the workplace. For example,hallways can be con gured with small niches, equipped with a whiteboardand a small shel or leaning, co ee cups are other materials.

Distraction is a major consideration or collaboration workplaces. Distraction can take two orms - activity that distractsthose not participating and distraction rom outside the group involved in collaboration. Minimizing distraction servesto improve collaboration and also ad-dresses concerns with in ormation security. Thus, attention to the acousticcharacteristic o collaboration workplaces, both ormal and in ormal is essential. Similarly, sight lines and visualdistractions should be considered, especially or in ormation displays.

ConclusionHealthcare environments possess signi cant untapped potential or bene ts to organizations willing to apply ergonomicsto sta workplaces. Evidence supports investing in workplace ergonomics to realize improved per ormance, improved

worker satis action, positive a ect on recruiting and retention and improved quality o patient care.


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Annotated Bibliography & In ormation Resources

The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Cameron Nelson, MPP, Terry West, MBA, Cli ord Goodman, PhD

Agency or Healthcare Research and QualityU.S. Department o Health and Human Services

AHRQ Publication No. 05-0106-EF August 2005

A body o evidence is developing about how attributes o the various environments in which healthcare is providedmediate healthcare quality. But no one has yet identi ed what questions remain to be answered that might help healthservices researchers, architects, or others decide where more research is needed or how research dollars could be bestspent to address the many outstanding issues. This environmental scan is intended to assess what is and is not knownabout the relationships between hospital design and constructionthe built environmentand:

1. Patient outcomes

2. Patient sa ety and satis action

3. Hospital sta sa ety and satis action

Hospital design and construction is vital, yet costly, to our healthcare system. An estimated $200 billion will be spenton new hospital construction across the United States in the next 10 years (6). Among the actors driving the market orhospital design and construction are: 1) competition or patient market share; 2) technology innovation and di usion; 3)e ciency and cost e ectiveness; and 4) regulatory compliance.

Despite the enormous expenditures projected or new hospital construction, there remains considerable potential orquality improvement in our nations hospitals. The Institute of Medicines widely cited report, To Err is Human, concthat tens o thousands o patients die each year rom preventable medical errors while in the hospital (6). Furthermore, upto two million U.S. hospital patients contract dangerous in ections during their hospital stays that complicate treatment and

requently result in adverse patient outcomes (6).

Hospital physical environments also can create stress or patients, their amilies and sta . This stress derives rom actorssuch as excessive noise due to hospital alarms, paging systems and equipment; eelings o helplessness and anxietytriggered by poor signage, con using building and corridor lay-outs and other fawed aspects o hospital design; and lackof privacy as a result of double-occupancy rooms. These may disturb a patients rest, more readily enable transmissioin ection and prompt the need or more requent, time-consuming and potentially error-inducing patient trans ers (6).

Due to growing knowledge and awareness o these issues, the hospital built environment increasingly is being infuenced

by research linking the physical environment to patient outcomes and patient and sta sa ety and satis action. Consistentwith the growing movement to apply clinical evidence-based approaches to improve patient outcomes, hospitaladministrators and researchers also are placing greater emphasis on evidence-based design to support and acilitateclinical advances in the eld (7).This is a process or creating hospital environments that is in ormed by the best availableevidence concerning how the physical environment can affect patient-centered care and staff safety and satisfaction (8)However, the eld is relatively new, evidence supporting this approach is not yet robust in many areas and existing researchon evidence-based hospital design is not widely known among policymakers, regulators and other decision-makers andopinion leaders.

These issues are discussed in the remainder o this environmental scan, which includes the ollowing sections:

What is currently driving the market for hospital design and construction?

To what extent are hospitals requesting evidence-based designs?

What is the research base for the hospital built environment?

What are major challenges in building the eld of evidence-based hospital design?What are the major gaps in current research and relevant areas of future focus?

What are appropriate roles for funders of health services research interested in furthering improvements within the built environment?


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The Role o the Physical Environment in the Hospital o the 21st Century: A Once-in-a-Li etime OpportunityRoger Ulrich*, Xiaobo Quan, Center or Health Systems and Design, College o Architecture, Texas A&M UniversityCraig Zimring*, Anjali Joseph, Ruchi Choudhary, College o Architecture, Georgia Institute o Technology

Report to The Center or Health Design or the Designing the 21 Century Hospital Project. This project is unded by the Robert Wood Johnson Foundation.

September 2004

According to the Institute o Medicine in its landmark Quality Chasm report: The rustration levels o both patients andclinicians have probably never been higher. Yet the problems remain. Healthcare today harms too requently and routinely

ails to its bene ts (IOM, 2001). Problems with U.S. healthcare not only infuence patients; they impact sta . Registerednurses have a turnover rate averaging 20 percent (Joint Commission on Accreditation o Healthcare Organizations, 2002).

At the same time, the United States is acing one o the largest hospital building booms in US history. As a result o a confuence o the need to replace aging 1970s hospitals, population shi ts in the United States, the grayingo the baby boom generation, and the introduction o new technologies, the United States will spend more than $16 billion

or hospital construction in 2004, and this will rise to more than $20 billion per year by the end o the decade (Babwin,2002). These hospitals will remain in place or decades.

This once-in-li etime construction program provides an opportunity to rethink hospital design, and especially to considerhow improved hospital design can help reduce sta stress and atigue and increase e ectiveness in delivering care,improve patient sa ety, reduce patient and amily stress and improve outcomes and improve overall healthcare quality.

Just as medicine has increasingly moved toward evidence-based medicine, where clinical choices are in ormed byresearch, healthcare design is increasingly guided by rigorous research linking the physical environment o hospitals topatients and sta outcomes and is moving to-ward evidence-based design (Hamilton, 2003).

What can research tell us about good and bad hospital design?

Is there compelling scienti cally credible evidence that design genuinely impacts staff and clinical outcome

Can improved design make hospitals less risky and stressful for patients, their families, and for staff?

The research team ound rigorous studies that link the physical environment to patient and sta outcomes in our areas:

1. Reduce sta stress and atigue and increase e ectiveness in delivering care

2. Improve patient sa ety

3. Reduce stress and improve outcomes

4. Improve overall healthcare quality

Recommendations and select evidentiary support:

1. Reduce Staff Stress and Fatigue and Increase Effectiveness in Delivering Care

There is a growing nurse shortage, and this directly threatens patient sa ety. And the existing hospital-basednursing orce is aging. Registered nurses in the United States average more than 43 years old and will average50 by 2010 and have a turnover rate averaging 20 percent per year (JCAHO, 2002).

A. Improve Sta Health and Sa ety through Environmental MeasuresPoor ergonomic design of patient beds and nurses stations leads to back stress, fatigue, and oinjuries among nursing sta . Reducing sta stress by ergonomic interventions, as well as care ulconsideration o other issues such as air quality, noise, and light, can have signi cant impact onsta health. (p.4)

B. Increase Sta E ectiveness, Reduce Errors, and Increase Sta Satis action by DesigningBetter WorkplacesJobs by nurses, physicians, and others o ten require a complex choreography o direct patientcare, critical communications, charting, lling meds, access to technology and in ormation, andother tasks. Many hospital settings have not been rethought as jobs have changed, and, as a result,the design o hospitals o ten increases sta stress and reduces their e ectiveness in deliveringcare. While much research in the hospital setting has been aimed at patients, there is a growing andconvincing body o evidence suggesting that improved designs can make the jobs o sta mucheasier.


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Nurses spend a lot of time walking. According to one study, almost 28.9 percent of nursing stafftime was spent walking (Burgio, Engel, Hawkins, McCorick, & Scheve, 1990). This came secondonly to patient-care activities, which accounted or 56.9 percent o observed behavior. At least ourstudies have shown that the type o unit layout (e.g. radial, single corridor, double corridor) infuencesamount o walking among nursing sta (Shepley, 2002; Shepley & Davies, 2003; Sturdavant, 1960; Trites, Galbraith, Sturdavant, & Leckwart, 1970), and two studies showed that time saved walkingwas translated into more time spent on patient-care activities and inter-action with amily members.

Sturdavant (1960) ound that ewer trips were made to patient rooms in radial units as nurses wereable to better supervise patients visually rom the nursing station, though the average time spent withpatients was the same in radial as well as single- corridor designs. Shepley and colleagues (2003)

ound that nursing sta in the radial unit walked signi cantly less than sta in the rectangular unit(4.7 steps per minute versus 7.9 steps per minute). However, Shepley and her colleagues noted thatradial designs might provide less fexibility in managing patient loads. Trites and colleagues (1970)

ound that decrease in the percentage o time spent walking by sta in radial units was correlated toan increase in the percentage o time spent in patient-care activities. Also, the majority o the sta surveyed preferred to work in the radial units. Hendrichs research showed that decentralized nursestations reduced sta walking and increased patient-care time, especially when supplies also weredecentralized and placed near the nurses station (Hendrich, 2003; IOM, 2004). Centralized locationo supplies, however, could double sta walking and substantially reduce care time irrespective o whether nurses stations were decentralized (Hendrich, 2003) (5-6)

Workplace design that refects a closer alignment o work patterns and the physical setting, such asredesign o a pharmacy layout, has been shown to improve work fow and reduce waiting times, aswell as increase patient satis action with the service(Pierce, Rogers, Sharp, & Musulin, 1990).

Other aspects o the environment, such as lighting levels and auditory or visual distractions, can alsoa ect sta e ectiveness while per orming critical tasks suchas dispensing medical prescriptions.

2 Improve Patient Sa ety

A. Hospital-Acquired In ectionsOne critically important way that evidence-based design improves sa ety is by reducing risk romhospital-acquired in ections. The research team identi ed more than 120 studies linking in ectionto the built environment o the hospital. Transmission o in ection to patients occurs through twogeneral routes: airborne and contact. The research literature shows that the design o the physical

environment strongly impacts hospital-acquired in ection rates by a ecting both air-borne andcontact transmission routes.

B. Reducing In ections Caused by Airborne Pathogens

C. Reducing In ections by Increasing Hand Washing

D. Reducing In ections with Single-Bed Rooms

E. Reducing Medication Errors The research team identi ed three rigorous studies that link environmental actors, such as lighting,distractions, and interruptions, with errors in prescribing or dispensing medications (Booker &Roseman, 1995; Buchanan, Barker, Gibson, Jiang, & Pearson, 1991; Flynn et al., 1999).

F. Reduce Patient Falls

G. Improve Patient Con dentiality and PrivacyCon dentiality has emerged as a priority issue in light o research showing that physicians andnurses very requently breach patient con dentiality and privacy by talking in spaces where they areoverhead by other patients or persons (Ubel, Zell, & Miller, 1995). The seriousness o the problemis underscored, or example, by a study o an emergency department at a university hospital thatshowed that 100 percent o physicians and other clinical personnel committed con dentialityand privacy breaches (Mlinek & Pierce, 1997). HIPAA, the Health Insurance Portability and


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Accountability Act of 1998, has further elevated the importance of providing reasonable safeguato protect the con dentiality o sta conversations with and about patients.

3 Reduce Stress and Improve Outcomes

A. Reduce Noise The research reviewed suggests that hospitals are excessively noisy or two general reasons

(Ulrich, Lawson, & Martinez, 2003). First, noise sources are numerous, often unnecessarily so,many are loud. Well-documented examples include paging systems, alarms, bedrails moved up/ down, telephones, sta voices, ice machines, pneumatic tubes, trolleys, and noises generated byroommates. Second, environmental sur acesfoors, walls, ceilingsusually are hard and sound-refecting, not sound- absorbing, creating poor acoustic conditions. Sound-refecting sur acescause noise to propagate considerable distances, traveling down corridors and into patient rooms,and adversely a ecting patients and sta over larger areas. Sound-refecting sur aces typical o hospitals cause sounds to echo, overlap, and linger or have long reverberation times (Blomkvist etal., in press, 2004; Ulrich et al., 2003).

The Role o the Physical and Social Environment in Promoting Health, Sa ety,and Effectiveness in the Healthcare Workplace

Anjali Joseph, Ph.D., Director o Research, The Center or Health Design Issue Paper #3 November 2006

Abstract

Objective To examine how the physical environment, along with other actors such as culture and social support, impact (a) the healthand sa ety o the care team, (b) e ectiveness o the healthcare team in providing care and preventing medical errors, and(c) patient and practitioner satis action with the experience o giving and receiving care.

MethodsLiterature review of peer-reviewed journal articles and research reports published in medicine, nursing, psychology,ergonomics, and architecture periodicals and books. Di erent combinations o keywords were used to search or articlesincluding work orce, nurses, health-care team, work environments, ergonomics, sta health, sta sa ety, medical errors,

trans ers, and communication.

Key Findings There is an urgent need to address the inherent problems in the healthcare work-place that lead to sta injuries andhospital-acquired in ections, medical errors, operational ailures, and wastage. The physical environment plays animportant role in improving the health and sa ety or sta , increasing e ectiveness in providing care, reducing errors, andincreasing job satis action. These improved outcomes may, in turn, help in reducing sta turnover and increase retention two key actors related to providing quality care in hospitals. However, it has be-come increasingly clear that e orts toimprove the physical environment alone are not likely to help an organization achieve its goals without a complementaryshi t in work culture and work practices. Proper design o healthcare settings, along with a culture that prioritizes the healthand sa ety o the care team through its policies and values, can reduce the risk o disease and injury to hospital sta andprovide the necessary support needed to per orm critical tasks. Also, it is important to identi y core systemic and acilitydesign actors that lead to ailures and wastage in healthcare, and then develop new solutions (e.g. acuity adaptability,standardized rooms) that address these problems within the context o culture changes and evolving models o care.

Conclusions The physical environment along with social support, organizational culture, and technology can play an important role inimproving health, sa ety, e ectiveness and satis action o the healthcare team.


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Review o Health and Productivity Gains rom Better IEQWilliam J. FiskIndoor Environment Department, Lawrence Berkeley National Laboratory, Berkeley, CA. Proceedings o Healthy Buildings 2000 Vol. 4. 23-34.

Abstract

The available scienti c data suggest that existing technologies and procedures can improve in-door environmentalquality (IEQ) in a manner that signi cantly increases productivity and health. While there is considerable uncertainty in theestimates o the magnitudes o productivity gains that may be obtained, the projected gains are very large. For the U.S.,the estimated potential annual savings and productivity gains are $6 to $14 billion rom reduced respiratory disease, $2 to$4 billion rom reduced allergies and asthma, $10 to $30 billion rom reduced sick building syndrome symptoms, and $20to $160 billion rom direct improvements in worker per ormance that are unrelated to health. Productivity gains that arequanti ed and demonstrated could serve as a strong stimulus or energy e ciency measures that s imultaneously improvethe indoor environment.

Enhancing Patient Sa ety in a Healing EnvironmentPatricia C. Sei ert, RN, MSN, CNOR, CRNFA, FAAN; Deborah S. Hickman, RN, BSN, MS, CNOR, CRNFA

Topics in Advanced Practice Nursing eJournal. 2005;5(1) 2005 Medscape

Abstract

The concept o a healing environment traditionally has been de ned in terms o clinical skill and technological resources. As both patients and their healthcare providers expand the concept o healing and how and where it takes place, thereis a greater emphasis on other aspects o the environment namely, aesthetic, ergonomic, and sa ety actors that helpcreate a sa e healing environment. This paper describes ndings rom environmental research that a ect the sa ety and thesatis action o patients and healthcare providers.

Physical Environment

One o the earliest proponents o the importance o the physical environment was Florence Nightingale (21).Her e orts onbehal o the British soldiers during the Crimean War ocused on design engineering to improve lighting (especially withsunlight), ventilation, heating and cooling, sewerage facilities, and suf cient space for soldiers personal belongings. Thsafety aspects of clean air and water were not inconsequential to Nightingales patients or to her nurses; the effectsimprovements on patient outcomes were re ected in the mortality gures for 1855, which fell from 42.7 deaths per2 per 1000 within 3 months of Nightingales changes (22).

More recently, environmental actors such as noise, air quality, light, toxic exposures, temperature humidity, and aestheticshave been scrutinized or their e ects on both patients and workers (3).The combination o environmental actors with thegrowing consumer demand or sa ety, security, competence, and physical and psychological com ort has engenderedthe concept of a healing environment. Healthcare designers in 1988 initiated the concept of a healing environmentcould acilitate the healing process by identi ying actors that improve access to people and resources, increase employeecom ort, expand patient privacy (eg, by reducing noise and distractions), and provide fexibility and personalization inthe delivery o care (23).In the past ew years, healthcare designers and healthcare acilities have ormed partnerships toincorporate healing environment design aspects into their renovation and new construction projects, and to measure thee ects o these initiatives on patient outcomes. One o the best known o these integrative e orts is The Pebble Project.


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Work Environment, Job Attitude, and Job Performance Relationships in Outpatient Healthcare Clinics.I. Facility and Position Differences. Butler, Mark C. ; Jones, Allan P.NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA 30 DEC 1980

Abstract

Perceptions o the work environment were related to job attitudes and per ormance measures or personnel assigned tove outpatient healthcare clinics as part o a multistage, systematic investigation o organizational actors and practices that

infuence the delivery o healthcare. Speci cally, the report presents (a) acility by acility comparisons and (b) di erencesdue to the type o job (medical versus non-medical) and sex o the healthcare provider. Implications or healthcare deliveryare discussed.

Culture, the built environment and healthcare organizational per ormance Authors: Mallak L.A.; Lyth D.M.; Olson S.D.; Ulshafer S.M.; Sardone F.J. Source: Managing Service Quality, Volume 13, Number 1, 2003 , pp. 27-38(12) Publisher: Emerald Group Publishing Limited

AbstractHealthcare organization per ormance is a unction o many variables. This study measured relationships among culture,the built environment, and outcome variables in a healthcare provider organization. A culture survey composed o existingscales and custom scales was used as the principal measurement instrument. Results supported culture strengthslinks with higher performance levels and identi ed the built environments role as a moderating variable that can leadimproved processes and outcomes. Job satis action and patient satis action were ound to be signi cantly and positivelycorrelated with culture strength and with ratings o the built environment.

Strategic real-estate planning can generate revenue: Organizations with less real estate ontheir balance sheet have produced higher fnancial returns than those with heavy investments inreal estate - healthcare industry

Healthcare Financial Management, Dec, 2001 by Danny Hayes, Steve Hays

Healthcare organizations real-estate holdings property, plant, and equipment typically represent one of the highecost categories or a healthcare organization, a ter salaries. For years, leading Fortune 500 companies have success ullymanaged their real-estate assets to minimize expenses. Although some healthcare organizations are taking steps topro t rom real-estate holdings, many others are not. An Ernst & Young study o executives o the largest U.S. health-careorganizations ound that many o them are not optimizing real-estate holdings or the ollowing reasons: (a)

Healthcare organizations generally lack a strategic plan for the use of their real estate;

The industry is not managing construction and expansion effectively despite having a surplus o space;

Healthcare organizations are not, on the whole, adapting and reusing their facilities; and

Organizations are not pursuing innovative real-estate strategies.


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Job discontent fuels aggressive recruitment of nurses Bull World Health Organ vol.79 no.12 Genebra 2001

A worldwide shortage o nurses has led wealthier nations to conduct aggressive campaigns to recruit nurses rom poorercountries. While the nurses who leave may nd higher wages and better working conditions in their new locations, thehome countries they leave behind su er the loss o highly trained health personnel who are not easily replaced.

One example of that movement is the United States recruitment of nurses from the Philippines, whose government hpolicy allowing nurses to migrate to other countries. According to Ms Cheryl Peterson, director o the International NursingCenter at the American Nurses Association (ANA), special schools with curricula and testing standards comparable tothose in the US have been established Philippines government to train nurses for work in the US. The problem, sayPeterson, is that the US is not only recruiting graduates rom these programmes but has also started tapping more highlyskilled and less easily replaced nurses, such as those who work in emergency rooms.

Job dissatis action, hazardous working conditions, and low job status are behind the nursing shortage in Westerncountries, according to a study published in the May/June 2001 issue of Nurses Reports by Dr Linda Aiken, a profenursing at the University o Pennsylvania School o Nursing in the USA. The study surveyed 43 000 nurses rom more than700 hospitals in Canada, Germany, the UK (England and Scotland), and the US. Among nurses under the age o 30 whoplanned to leave nursing within a year, young English and Scottish nurses were the most discontented, with 53% and 46%respectively planning on leaving. Salaries were also considered inadequate by a large proportion o the nurses surveyed,with only 20% o English nurses and only 26% o Scottish nurses reporting that their wages were acceptable. In the U.S.,according to ANA estimates, approximately hal -a-million men and women with active registered nurse licenses have le tthe pro ession.

Changing Demographics: Implications for Physicians, Nurses, and Other Health Workers U.S. Department o Health and Human Services Health Resources and Services Administration Bureauo Health Pro essions National Center or Health Work orce AnalysisSpring 2003http://bhpr.hrsa.gov/healthworkforce/reports/changedemo/Content.htm

A new HRSA report on workforce trends predicts that the percentage of a physicians time spent treating elderly andminority patients will increase markedly in coming years.

The report reviewed and summarized literature on U.S. demographic projections and their implication or the healthwork orce. Selected ndings ocused on:

Aging Population: The elderly (age 65 and over) currently represent 13 percent o the U.S. population, expectedto rise to 17 percent by 2020. By 2020 almost 40 percent o a physician=s time will be spent treating theelderly. The health work orce also is aging and many health pro essionals are expected to retire at a time whendemand or services is on the rise.

Racial and Ethnic Diversity: Demand or healthcare services by minorities is expected to increase as thepercentage o minorities in the U.S. population grows. There ore, the time physicians spend treating minoritypatients is expected to grow rom some 31 per-cent in 2000 to 40 percent by 2020. As the number o minorities grows their participation in the work orce will rise similarly, causing minority under-representation inhealthcare to shrink.

Geographic Location o the Population: The number o people living in urban areas is going up. At the sametime, data show many Americans living in rural areas that are designated as physician shortage areas.

Differences in population growth rates and healthcare workers supply and demand highlight the importancdeveloping models that can provide state-level and substate-level work orce projections.


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The role o leadership in overcoming sta turnover in critical careKelly Roy and Fabrice BrunetCritical Care 2005, 9:422-423 doi:10.1186/cc3775

Abstract

This commentary discusses Laporta and coworkers analysis of a case study on the causes of and solutions for stafturnover in an intensive care setting. Sta turnover is a signi cant issue or healthcare leaders due to the shrinkingwork orce in Western countries and an increased demand or intensive care services as the population ages. Thecommentary considers reasons or turn-over such as burnout and generational diversity, and highlights the importance o ateam work approach to address the issue o turnover.

Determinants of Hospital Staff Nurse Turnover Carol S. Weisman, Cheryl S. Alexander, Gary A. ChaseMedical Care, Vol. 19, No. 4 (Apr., 1981), pp. 431-443

Abstract

Organizational and non-organizational determinants o sta nurse turnover are investigated in a panel study o 1,259 nursesemployed in two university-a liated hospitals. Findings are consistent with a causal chain in which perceived autonomy,

job satis action, intent to leave the hospital and turnover are a sequence o outcomes refecting the successive stages o anurses decision to resign. Both personal characteristics and job-related attributes are predictive at various stages of thprocess, although amily status variables have no signi cant e ects. Implications or hospital management o turnover arediscussed.

Imported Care: Recruiting Foreign Nurses to U.S. Healthcare Facilities Barbara L. Brush, Julie Sochalski and Anne M. Berger Health Affairs, 23, no. 3 (2004): 78-87 doi: 10.1377/hlthaff.23.3.78 2004 by Project HOPE

Abstract

As U.S. healthcare acilities struggle to ll current registered nurse sta ng vacancies, a more critical nurse undersupply ispredicted over the next twenty years. In response, many institutions are doubling their e orts to attract and retain nurses.

To that end, oreign nurses are increasingly being sought, creating a lucrative business or new recruiting agencies bothat home and abroad. This paper examines past and current oreign nurse use as a response to nurse shortages and itsimplications or domestic and global nurse work- orce policies.

NIOSH Publication No. 97-117:Elements of Ergonomics Programs A Primer Based on Workplace Evaluations o Musculoskeletal DisordersMarch 1997http://www.cdc.gov/Niosh/docs/97-117/default.html

This primer describes the basic elements o a workplace program aimed at preventing work-related musculoskeletaldisorders (WMSDs). Management commitment, worker participation, and training are addressed along with procedures oridenti ying evaluating, and controlling risk actors or WMSDs. The text cites NIOSH ergonomics investigations to illustratepractical ways or meeting program needs. The primer includes a toolbox, which is a collection o techniques, methods,re erence materials, and sources or other in ormation that can help in program development.


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Table o Contents

Disclaimer

Foreword

Overview

Acknowledgments

IntroductionStep 1. Looking For Signs of Work-Related Musculoskeletal Problems

Step 2. Setting the Stage or Action

Step 3. Training-Building In-House Expertise

Step 4. Gathering and Examining Evidence o WMSDS

Step 5. Developing Controls

Step 6. Healthcare Management

Step 7. Proactive Ergonomics

Re erences

Toolbox

Description o Contents

Tray 1. Looking For Signs of WMSDS

Tray 2. Setting the Stage or Action

Tray 3. Training Building In-House Expertise

Tray 4. Data Gathering-Medical and Health Indicators

Tray 5. Data Gathering-Job Risk Factors

Tray 6. Evaluating Job Risk Factors

Tray 7. Evaluating Control E ectiveness

Tray 8. Healthcare Management

Tray 9. Proactive Ergonomics

Tray 10. Other Primers and Manuals

List of Exhibits List of Checklists

General Workstation Design Principles*

1. Make the workstation adjustable, enabling both large and small persons to t com ortably and reach materialseasily.

2.Locate all materials and tools in front of the worker to reduce twisting motions. Provide suf cient workor the whole body to turn.

3. Avoid static loads, xed work postures, and job requirements in which operators must requently or or long

periods:a. Lean to the front or the side,

b. Hold a limb in a bent or extended position,

c. Tilt the head orward more than 15 degrees, or

d. Support the bodys weight with one leg.

4. Set the work sur ace above elbow height or tasks involving ne visual details and below el-bow height ortasks requiring downward orces and heavy physical e ort.


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5. Provide adjustable, properly designed chairs with the ollowing eatures

a. Adjustable seat height,

b. Adjustable up and down back rest, including a lumbar (lower-back) support,

c. Padding that will not compress more than an inch under the weight o a seated individual, and a

d. Chair that is stable to foor at all times (5-leg base).

6. Allow the workers, at their discretion, to alternate between sitting and standing. Provide foor mats or paddedsur aces or prolonged standing.

7. Support the limbs: provide elbow, wrist, arm, oot, and back rests as needed and easible.

8.Use gravity to move materials.

9. Design the workstation so that arm movements are continuous and curved. Avoid straight-line, jerking armmotions.

10. Design so arm movements pivot about th

healthcare ergonomics

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