safety, efficiency and flexibility – convergent or mutually exclusive goals in healthcare design

8/13/2019 Safety, Efficiency and Flexibility Convergent or Mutually Exclusive Goals in Healthcare Design

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Paul Barach, MD, MPH

Clalit SeminarOctober 1 2013

Safety, Efficiency and Flexibility Convergent or MutuallyExclusive Goals in Healthcare Design


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Wellness Model


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PATIENT CENTERED

TIMELY EFFICIENT

EFFECTIVE

SAFE

EQUITABLE

QUALITY

Components of Evidence based Quality/Design

QUALITY

FURNISHINGS

LIGHT MATERIALS

WAYFINDING

AROMA

ART


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Active

Event

Reporting

Passive

Indicators

Discharge

Data

Passive

Triggers

Medical

Records

Truth?

Looking

for Harm


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How Safe is Safe Enough???

How Does 99.9% Sound?


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Assuming a system is 99.9% safe, what

does that mean in the real world?

84 unsafe landings /day

1 major plane crash every 3 days

16,000 mail items lost/hr 37,000 bank transaction errors/hr


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Nosystembeyond

thispoint

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

Civil Aviation

Nuclear IndustryRailways France)

Chartered FlightimalayamountaineeringRoad Safety

Chemical Industry total)

Risk

Medical risk total)

Blood transfusionAnesthesiologyASA1

Cardiac SurgeryPatient ASA3-5

Fatal Iatrogenicadverse events

Microlight flightshelicopters

Very unsafe Ultra safe

Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safeHealth Care. Annals of Internal Medicine, 2005;142:756-764.

Adverse Event Rates in

Healthcare


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Minor Adverse Events and Patient Satisfaction AfterAnaesthesia:A Prospective Interview Study

Michael Lehmann, Kai Monte, Paul Barach, Christoph Kindler, MD JCA, 2010

!12, 347 cases; 29% minor adverse event that cause muchunhappiness and dissatisfaction, yet are not long lasting or

permanent.

!These minor events, however, cause much delay in healing and are


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DOES THE DAY OF WEEK MATTER?

operations performed on Fridays were associated with a higher30-day mortality rate than those performed on Mondays through

Wednesdays: 2.94% vs. 2.18%;Odds ratio, 1.36; 95% CI, 1.241.49)


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Mental Models"Our personal image of the world

None are perfectly accurate Differences in mental models explain howtwo people can understand the same event

differently

Are generally invisible to us until we lookfor them

10


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The Ladderof Inference(Peter Senge)

11


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Risk Model


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If an error is possible, someone willmake it. The designer must assumethat all possible errors will occur anddesign so as to minimize the chanceof the error in the first place, or itseffects once it gets made

Norman, The Design of EverydayThings, 2001


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!"#$% '( )"*+, -+.'(/01

2 !"#$ 3'"412 5%(56% #,'%/+.7,8 9#': *+.:#,%0

2 ;%(56% #,'%/+.7,8 9#': .(*5"'%/02 ;%(56% #,'%/+.7,8 9#': +"'(*+7(,

2 &'( 3'"412 ;%(56% 9(/


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System Factors That Impact Safety

Barach P & Small. Reporting and preventing medical mishaps: lessons from non-medical near miss

reporting systems. BMJ 2000;320:759-763

Staff Individual Factors

Team factors

Organisation

Factors

Technical Factors

Individual Factors

Patient Intrinsic Factors

National

Culture


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Solet J. and Barach P., 2012


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Human Factors : Re-engineering theperioperative process

Improve processes Improve ergonomics Integrate technologies

Optimize patient safety Increase throughput

Improve staffsatisfaction

Maintain protectedresearch environment

Bedside surgical interface Optimized monitor

placement

Develop smart alarms andautomated clinical decision

support

Develop interlocks acrossmedical device systems

Benefit of medical deviceinteroperability

Synchronization to mitigatehazard


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Reason Complex Systems


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HH: hand hygiene. OT: operating

theatre. NSG: non-sterile gloves.

SG: sterile gloves

Annelot C Krediet, et al. Hygiene

Practices in the Operating Theatre:

An Observational

Study., BJA, 2011


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Open bay Old single

room

New single

room

0%

60%

50%

40%

30%

20%

10%

27% 38% 47%

28%

increase

42%

increase

74%total increase

Ha

ndwashing

rate

Preliminary Findings (Quan and Ulrich,2005)


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2.25%

2.50%

2.75%

3.00%

3.25%

3.50%

3.75%

4.00%

4.25%

Er

rorRate

480 lux

Medication Dispensing Error Rates by Illumination

Level (Buchanan et al., 1991)

1100 lux 1550 lux

(Lighting on task, not ambient)250 lux


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Coping with innovation

How we make decisions optimizing vs.sacrificing

Spanning silos Testing new ideas

Late binding Confronting conflicts What if were wrong?

How does lean fit into this process?


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Hybrid Operating Room Defined

Procedure room designed for:

# open and/or closed surgicalprocedures

# configured for surgical sterile controlprecautions, including the establishment

of a surgical red-line of demarcation

# use of anesthesia# advanced image-guidance


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Key Design Challenges

# Future flexibility# Turf battles / decision-making# Available space, infrastructure, capital# Integration of clinical devices# Design for Surgery vs. Interventional

Procedures

Image, courtesy of Stantec


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Designing for Function

and Flexibility The Concept of the Interventional

Platform

Communication strategy at multiplelevels and scales

Tools to facilitate understanding


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The Interventional PlatformRealigning the Silos

TechnologyBased

Surgery

InterventionalImaging

Cardiac

Catheterization

Endoscopy

(natural orifice

access)

SystemsBased

Brain

Head and NeckLung

Heart

Vasculature

Breast

BoneIntestine

Kidney and

Bladder


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The Interventional PlatformShared Services

Service

Registration

Family Waiting

Pre-Op/PACU

Anesthesia

Pathology

Central Supply

Savings

Scheduling

ClearWayfinding

Reduce

positions

Colocation ofstaff

Colocation of

staff

Reduce space


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The Interventional

PlatformFlexible Technology


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The Interventional

PlatformFlexible Space


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The Interventional

PlatformFlexible Services


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The Interventional

PlatformFlexible Dimensions


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Flexibility Strategies


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Suite Design Strategies


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Room Design Strategies


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Communications Strategy IConsensus Building

Vision (from the top)

Alignment of Surgery/

Medicine

Alignment of Surgery/

Radiology

Cardiac Catheterization buy in

Playing by Surgical Rules

Code/Operational Issues

Culture Shock


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"


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

!"#$%" ()*+, -"+."&,*/" (%0&,

1", 230*+" 4"", 567 88

9+%## 230*+" 4"", :87 ;;6

!"#$% '()*"+)() ,-.


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Effectiveness of tools - AORN

(1= Not useful, 5=very useful)

" # $ % & '()*+

',*- -,,)./01 2 3456 7 3856 "4 3"#56 &% 3$756 &" 3$856 "$2

9/),:;.,?

@=A1.B.*/1? @*).,/)1

7 3856 "& 3""56 #C 3"&56 &" 3$256 %C 3$C56 "$&

$DE B(-@F),: -(G,+1 $$ 3#856 "C 3256 "7 3"&56 $" 3#&56 $C 3#%56 "#$

H(-@F),: 1.-F+*).(/

-(G,+ (>


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Communications Strategy IIScales of Consensus

The Big Idea (guiding principles)

Change management as normative (big idea)

Establishing a new hierarchy

Understanding group and individual loss

Leveling an unlevel playing field

Establishing small group alliances


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Tools to Facilitate UnderstandingSteps from the beginning

Program (numbers and narrative)

Adjacency and Flow Diagrams

Plans and Reflected Ceiling Plans

Elevations and Equipment Placement

3D Modeling and Scale Models

Full Scale Models and Simulation

Mock-ups with Equipment and Finishes


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Tools to Facilitate UnderstandingPlans and Reflective Ceiling Plans


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Tools to Facilitate Understanding3D Modeling


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Tools to Facilitate UnderstandingFull Scale Models and Simulation


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Results -Safety Culture in the OR

3 academic PCS teams were surveyedon: Adverse event reporting OR management Safety culture

72% response rate Significant differences (p


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Stages in the development of a safety culture

CALCULATIVEWe have systems in place to manage all hazards

PROACTIVESafety leadership and values drive

continuous improvement

REACTIVESafety is important, we do a lot every time we have an accidentPATHOLOGICALWho cares as long as we re not caught

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

Adapted from Westrum (1992, 2000


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Model of Big 5 Teamwork

Team

Leadership

Team

Orientatio

n

Mutual

Performance

Monitoring

Back-Up

Behavior

Adaptabilit

y

THE CORE

Baker, Salas, King, Battles, Barach, 2006


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Health care consumes

18%of US energyannually

Slide: 51

2009 Perkins+Will


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The Impact of Design on EBD

Outcomes

Source: Healthcare Leadership white Paper: Ulrich, Zimring, Zhu, DuBose, Seo, Choi, Quan, Joseph(2008)


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High-Priority Research Directions for Seeking to Built Safer and Sustainable Facili


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#Design of CardiovascularOperating Rooms for

Tomorrows Technology and

Clinical Practice Part One;

# B. Rostenberg, P. Barach; Progress inPediatric Cardiology; 32 (2011) 121-128

# Design of CardiovascularOperating Rooms for

Tomorrows Technology and

Clinical Practice Part Two;

# B. Rostenberg, P. Barach; Progress inPediatric Cardiology; 33 (2012) 57-65


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For copies of papers or tools

please email me at

[email protected]

safety, efficiency and flexibility – convergent or mutually exclusive goals in healthcare design

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