Informing Emerging

Models Through

Research

Eileen Malone, RN, MSN, MS, EDAC, Senior Partner,

Mercury Healthcare Consulting, LLC

Ann Sloan Devlin, PhD, May Buckley Sadowski ‘19

Professor of Psychology, Connecticut College

Tama Duffy Day, FIIDA, FASID, LEED AP BD+C, Global Interior Design

Healthcare Practice Leader, Perkins+Will

Agenda

• 2010 Patient Protection and Affordable Care Act Impacts

– Patient harm and reimbursement

– Making care more accessible and affordable

• Addressing Human Needs through Research

• Research Translation thru Design

• Questions and Discussion

National Strategy for Quality Improvement in Health Care

•Triple Aim

Better care

Healthy people/healthy communities

Affordable care

•National Quality Strategy Priorities

Making care safer by reducing harm caused in the delivery of care

Ensuring that each person and family are engaged as partners in their care

Promoting effective communication and coordination of care

Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease

Working with communities to promote the wide use of best practices to enable healthy living

Making quality care more affordable for individuals, families, employers and governments by developing and spreading new health care delivery models

Blueprint to prioritize quality improvement efforts, share lessons and measure collective success

Led by The Agency for Healthcare Research and Quality

Fueling Healthcare Safety Reform: Fix Safety or Suffer Financial Consequences

CMS reimbursement tied to quality

outcomes

Legislation

2005 DRA

2010 ACA

Public reporting of

safety outcomes

National Quality Strategy Long-Term Goals for Making Care Safer: 1. Reduce preventable hospital admissions and readmissions. 2. Reduce the incidence of adverse health care-associated conditions. 3. Reduce harm from inappropriate or unnecessary care.

Patient safety focus

Legislative-driven Healthcare Shift: From Payment for Volume to Quality • 2005 Defense Threat Reduction Act Section 5001(c)

Starting in FY 09, hospitals are no longer paid at the higher rate for the increased cost of care that results when a patient is harmed.

• 2010 Patient Protection and Affordable Care Act

• Patient safety and hospital-acquired conditions are targeted in

two CMS Programs:

– Hospital Value-Based Purchasing Program -

Reimbursement now tied to performance

• FY 13 – 30-day readmission rates and the patient

experience (HCAHPS) 2 HCAHP questions specific to

the environment – hospital cleanliness & quiet

• FY 14 – Mortality measures

• FY 15 – Patient safety indicators

• FY 16-17 Hospital acquired conditions and AHRQ

composite measures of quality

– Partnership for Patient Program – a national patient safety

and quality improvement initiative with10 focus areas

Partnership for Patient Goals

• Hospital Acquired Conditions (HACs): Reduce by 40%

– Adverse Drug Event (medication errors)

– Catheter-Associated Urinary Tract Infections

– Central Line Associated Blood Stream Infections

– Injuries from Falls and Immobility

– Surgical Site Infections

– Venous Thromboembolism

– Ventilator-Associated Pneumonia

– Pressure Ulcers

– Obstetrical Adverse Events

• Readmission rates: Reduce by 20%

http://partnershipforpatients.cms.gov/

Think Like the Owner Patient Harm + Dissatisfaction = $$ • Ask what problem(s) they are trying to solve and remember that money

drives many (almost all) decisions

• Non-reimbursement of the care associated with the injury

• Better safety scores = better publicity and potential increase in market share

• Cannot admit as many patients, because harmed patients remain in the hospital longer

• Cannot see as many ED and outpatients because they are not efficient – think throughput

• Litigation

You have important solutions to offer as a part of an integrated approach to solving these pernicious problems!

Remember, it is always about the $$$, whether it is the project itself or the costs associated with research.

THINK RETURN-ON-INVESTMENT BEYOND FIRST COSTS

Design Tools to Help Reduce HACs

Patient Goals Design Solutions

Adverse Drug Event (medication errors)

Illumination levels specific to task; Minimize interruptions and distractions; reduce noise; ergonomically designed and task organized work space (USP-NF, 2010)

HAIs (CAUTI, CLABSI, VAP, SSI)

Facilitate hand sanitation; easy to clean surfaces, fixtures, equipment and accessories; filter air contaminates – HEPA, UVGI

Falls and immobility related injuries

Clearances between the bed, chair and equipment; barrier-free access to the bathroom; flooring that is stable, firm, slip-resistant; with minimum joints, low reflectance value and low-contrast flooring patterns; furniture that is sturdy, stable and of a design and seat height appropriate to the patient using it.

Venous Thromboembolism & Pressure Ulcers

NEED RESEARCH! What about the role of ceiling mounted lifts as a component of a comprehensive patient handling and movement program?

Readmissions NEED RESEARCH! Does the family zone result in more family member engagement in discharge planning and fewer readmissions?

The Center for Health Design’s Knowledge Repository

With support from: • The American Institute of

Architects Academy of Architecture for Health

• The Academy of Architecture for Health Foundation

• The American Society for Healthcare Engineering

• The Facility Guidelines Institute • Research Design Connections • Nursing Institute for Healthcare

Design

• Decision making tool

• 2,600 + article references

• Acute, Residential, Ambulatory care

• 100 Key point summaries and growing – condensed summaries written in lay language

• Conceptual models

https://www.healthdesign.org/search/articles

Search by environmental feature and healthcare

outcome

48.6 MILLION AMERICANS HAVE NO HEALTH INSURANCE

Making Care More Accessible and Affordable

Community health center-based

preventive care

Expand the number of medical homes

Harness health IT

Expand Medicaid

Employer mandated insurance

Health insurance exchanges

• Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured

• Emphasize primary and preventive care linked with community prevention services

• Ensure access to quality, culturally competent care for vulnerable populations

• Promote the adoption and meaningful use of health information technology

Consequence: Ambulatory care growth & healthcare system acquisitions and mergers

Design Solutions for Outpatient Care Goal Possible Design Solutions

Practice organization

Team rooms to encourage care coordination and hand-offs; designed to maximize throughput; standardization for flexibility

Patient centered care

Patient versus assembly-line care Kiosk, check-in, way finding Space in the exam room (outpatient room) for family

Quality care Many are the same as listed for the Partnership for patients

Health IT Seamlessly integrated with the processes of care and the built environment

http://www.aafp.org/practice-management/pcmh/overview.html

Patient-centered Medical Home

The Patient-Centered Medical Home (PCMH) model is an approach to providing comprehensive primary care for children, adolescents, and adults. The PCMH is a health care setting that facilitates partnerships between patients and their personal physicians, and when appropriate, the patient's family. American Academy of Family Practice

Source for Outpatient Design Solutions

•

http://www.healthdesign.org/clinic-design

The Center for Health Design • Learning about the design

process • View design

recommendations • News • Solution library • Words of advice

There is less evidence-based design research for the ambulatory care setting compared with the

inpatient setting.

Research in Healthcare Settings:

Values and Strategies

Ann Sloan Devlin, PhD Connecticut College

Overview

•Models of Care Change: Humans do not

•Research Continuum and Its Challenges:

Anecdotes----------------------Experiments

•Solution: Multi-method, simulation, and satisficing

Characteristics of Humans

•Build mental models (schemas)

•Value choice, control, and competence

•Evolved in nature

Schemas

Schemas and healthcare Expectations:

consumer- and hospitality-oriented

L&M Cancer Center Waterford CT Thundermist Health Center West Warwick, RI Vision 3 Architects Aaron Usher III Photography

Bronson Methodist Hospital, Planetree affiliate Kalamazoo Michigan

Value Choice, Control, and Competence

•Choice matters—e.g., seating

Yale New Haven Hospital Adult Emergency Waiting Area

•Control can provide privacy

Women & Infants Center for Reproduction and Infertility, Providence, RI

Research on privacy

Privacy breaches neg. impact

-- e.g., overhearing conversations about

other patients

“You feel healthier when you’re dressed”1

•Competence –figuring it out for yourself

[Wayfinding research]

Cue Identity/ repetition

Color + alphanumeric

Humans evolved in nature

L&M Cancer Center Waterford CT Office of Neeraj Kohli MD MBA

The Research Continuum

• Anecdotes----------------------Experiments

“True” Experiments:

--Random assignment to condition

--Manipulate a variable (usually one)

--Enough participants to account for

variability within the sample

--CHALLENGES FOR HEALTHCARE RESEARCH

Controlled research: Small scale

•Use of music for pain management

1) headphones or speaker system

2) Usually a between-subjects design

3) Advantages in personally selecting or choosing music selections

“Large” scale example:

Same-handed vs. mirror-image inpatient

rooms

--Quality of sleep

--Fewer near falls

--Nurse satisfaction with room arrangement

http://www.hermanmiller.com/discover/ improve-care-save-money-can-standards-do-both/

Archival example:

Ulrich’s “view from a window” study

-----Archival

------Used matched group design

-----Multiple dependent variables:

objective & subjective

BUT

He didn’t measure the light levels in each room

Light, therefore, is a confounding variable---

i.e., light can’t be separated out from the view

(at least in THAT study)

Challenges of Post-Occupancy Evaluations (POEs)

Pre-post designs (measure before & after)

Solomon 4 group design: The Gold Standard

(1) Pre Intervention Post (~experimental)

(2) Pre Post (~control)

(3) Intervention Post

(4) No Intervention Post

Needed areas of research

•Waiting rooms

•Technology

• Safety

Research on waiting rooms

With Affordable Care Act:

-----more walk-in clinics,

-----longer waits

Technology: Ubiquitous

•Electronic medical records (EMRs)

• Health information and the Internet

For the first half of 2009, more than 50%

of Americans aged 18-64 used the

Internet to look up health information1

1Reuter’s poll

Research on doctor-patient communication

•How EMRs affect doctor-patient communication (DPC)

Thundermist Health Center Warwick RI Vision 3 Architects Aaron Usher III Photography

With EMRs decrease in time

med students look at patients

Only 21% of medical students agreed:

“My patients liked that I was using an EHR”

[electronic health record]

Steelcase + Mayo Clinic collaborate on Consultation Space

Shape of table/arrangement of chairs to see monitor1

Jack-and-Jill room (~The Brady Bunch)2

-Exam room flanked by 2 consultation rooms

-Family nearby for consultation

Jack-and-Jill Room

http://www.mayoclinic.org/annualreport/2011/innovation/ jack_and_jill_rooms.html

Furnishings: Technology + Waiting

Regard™ line for Nurture® by Steelcase was introduced at the 2012 Healthcare Design Conference and won a gold Nightingale award for guest seating.

Safety By regulation (good)

By association (better)

To Address Challenges of Research in Healthcare Settings

-use a variety of approaches:

(multi-method)

-start with simulation

-consider satisficing

– Concept from Nobel laureate Herbert Simon

• “The best is the enemy of the good”

References Almquist, J. R., Kelly, C., Bromberg, J., Bryant, S. C., Christianson, T. J. H., & Montori, V. M. (2009). Consultation room design and the clinical encounter: The space and interaction randomized trial. Health Environments Research & Design Journal, 3(1), 41-78.

Cooke, M., Chaboyer, W., & Hiratos, M. A. (2005). Music and its effect on anxiety in short waiting periods: A critical appraisal. Journal of Clinical Nursing, 14, 145-155. doi:10.1111/j.1365-2702.2004.01033.x

Dickson, F. (2010). Devola Funk’s health care reminder: “You feel healthier when you’re dressed.” http://blog.centerforinnovation.mayo.edu/2010/11/23/ devola-funk’s-health-care-reminder-”you-feel-healthier-when-you’re dressed-”/

http://www.hermanmiller.com/discover/improve-care-save-money-can- standards-do-both/ Karro, J., Dent, A. W., & Farish, S. (2003). Patient perceptions of privacy infringements in an emergency department. Emergency Medicine Australasia, 17(2), 117-123. doi:10.1111/j.1742-6723.2005.00702.x

Lee, K.-C., Chao, Y.-H., Yiin, J.-J., Chiang, P.-Y., & Chao, Y.-F. (2011). Effectiveness of different music-playing devices for reducing preoperative anxiety: A clinical control study. International Journal of Nursing Studies, 48, 1180-1187. doi: 10.1016/j.ijnurstu.2011.04.001

http://www.mayo.edu/center-for-innovation/what-we-do/design-thinking

http://www.mayoclinic.org/annualreport.2011./innovation/ jack_and_jill_rooms.html

Rouf, E., Chumley, H. S., & Dobbie., A. E. (2008). Electronic health records in outpatient clinics. BMC Medical Education, 8(13), 1-7. doi:10.1186/1472-6920-8-13

Routhieaux, R. L., & Tansik, D. A. (1997). The benefits of music in hospital waiting rooms. The Health Care Supervisor, 16, 31–40.

Shachak, A., & Reis, S. (2009). The impact of electronic medical records on patient- doctor communication during consultation: A narrative literature review. Journal of Evaluation in Clinical Practice, 15, 641-649. doi:10.1111/j. 1365-2753.2008.01065.x

Simon, H. A. (1970). Style in design. In J. Archea & C. Eastman (Eds.), EDRA 2: Proceedings of the 2nd Environmental Design Research Association Conference (pp. 1-10). Stroudsburg, PA: Dowden, Hutchinson, and Ross.

Ulrich, R. S. (1984). View through a window may influence recovery from surgery. Science, 224, 420-421. doi:10.1126/science.6143402

Watkins, N. W., Kennedy, M. M., Ducharme, M. M., & Padula, C. C. (2011). Same- handed and mirrored unit configurations: Is there a difference in patient and nurse outcomes? Journal of Nursing Administration, 41, 273-279. doi: 10.1097/NNA.0b013e31821c47b4

RESEARCH TRANSLATION THRU DESIGN

OCTOBER 2013

TAMA DUFFY DAY FIIDA, FASID, LEED AP BD+C

FACILITY CHALLENGES

MISSION + CULTURE + SOCIAL SPACE / PHYSICAL SPACE

+ WHO IS YOUR CLIENT

PROGRAMMING AND PLANNING TO REDUCE COSTS + EFFICIENCY / BUSINESS MODEL

+ TEAM-CENTRIC /

+ PATIENT-CENTERED

IMPROVING OUTCOMES + PATIENT SAFETY

+ PATIENT SATISFACTION

+ PATIENT EDUCATION

+ CARE GIVER HEALTH

+ DESIGN SOLUTIONS

MISSION+CULTURE

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SOCIAL SPACE /

PHYSICAL SPACE /

WHO IS YOUR CLIENT?

JUANITA J. CRAFT DIABETES CENTER DALLAS, TX

JAFFE FOOD & ALLERGY INSTITUTE NEW YORK, NY

DUKE MAMMOGRAPHY SUITE DURHAM, NC

STONACH CANCER CENTRE NEWMARKET, ONTARIO

OBSERVATION / MAPPING

PATIENT AND STAFF SURVEYS

PRE-OCCUPANCY EVAULATON

EFFICIENCY / BUSINESS MODEL /

TEAM CENTRIC /

PATIENT-CENTERED /

PROGRAMMING AND PLANNING TO REDUCE COSTS

www.post-gazette.com www.bet.com

FAMILY CONSULT

144 SQ FT

EXAM

120 SQ FT

DENTAL SURGERY

140 SQ FT

UNIVERSAL ROOM

120 SQ FT

BEHAVIORAL

DENTAL

EXAM

CONSULT

TREATMENT

OFFICE

OFFICE C

64 SQ FT

OFFICE B

100 SQ FT

OFFICE A

120 SQ FT

DENTAL DIRECTOR

96 SQ FT

CONSULTATION

100 SQ FT MEDICAL DIRECTOR

102 SQ FT

DENTAL OPERATORY

120 SQ FT

CASE MANAGER

120 SQ FT

PROVIDER

120 SQ FT UNIVERSAL ROOM

LEVEL 3: MEDICAL CLINIC LEVEL 4: ADMINISTRATIVE

LEVEL 1: ADMIN / EDUCATION / WELCOME CENTER LEVEL 2: DENTAL / BEHAVIORAL HEALTH

UNIVERSAL FLOOR PLAN

LEVEL 3: MEDICAL CLINIC

TEAM ROOM / EXAM ROOM CLUSTER

6 6 6

PATIENT FLOW

6

7 10 8 9

1 2 3 4 5

11 12

PROGRAM REFLECTS MISSION

2008 2009 2011

11,0

00 +

9,00

0 +

7,80

0 +

720

$1,0

00,0

00.

698

$816

,000

631

$800

,000

2008 2009 2011

GROWTH IN PATIENT VOLUMES / GROWTH IN VOLUNTEERS AND VALUE

IMPROVING OUTCOMES

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PATIENT EDUCATION

PATIENT SAFETY

PATIENT SATISFACTION

CARE GIVER HEALTH

LEVEL 2

LEVEL 1

LEVEL 4

LEVEL 3

LEVEL 2

LEVEL 1

LEVEL 4

LEVEL 3

Original program / plan Revised program / plan

COMMUNITY HEALTH – PATIENT

EDUCATION

COMMUNITY HEALTH / PATIENT EDUCATION

100% RESPONDED THAT THE NEW CLINIC SPACE

IS LIGHT-FILLED AND UPLIFTING.

79% THOUGHT THAT MORE COMMUNITY ACTIVITIES

AND EDUCATION WILL OCCUR AS A RESULT OF

THE NEW CONFERENCE SPACE AREA.

75% INDICATED THAT THE NEW SPACE

INSPIRES HEALTH.

PATIENT SAFETY - EXAM ROOMS

PATIENT SAFETY - EXAM ROOMS

PATIENT SAFETY - EXAM ROOM VISIBIILTY

PATIENT SATISFACTION / WAYFINDING

PATIENT SATISFACTION / POSITIVE

DISTRACTION

PATIENT SATISFACTION / PRIVACY

PATIENT SATISFACTION / DAYLIGHT AND VIEWS

PATIENT SATISFACTION / AMENITIES

CARE GIVER HEALTH

CARE GIVER HEALTH

CARE GIVER HEALTH

EVIDENCE-BASED DESIGN IS THE

PROCESS OF BASING DECISIONS

ABOUT THE BUILT ENVIRONMENT ON

CREDIBLE RESEARCH TO ACHIEVE

THE BEST POSSIBLE OUTCOMES THE CENTER FOR HEALTH DESIGN

WELLNESS

ILLNESS

SHARE

ANALYZE

TEST

HYPOTHESIZE

ACA-generated transformation demands design solutions as a component of an integrated

approach in order to resolve chronic safety, quality, access and cost issues

Credible solutions are based on the evidence - be prepared, educate the owner

Make sure you understand the owner’s goals - you cannot design what you cannot describe

Focus the research on patient, staff and resource outcomes - study the impact of your design

decisions

Think beyond first costs - understand the healthcare business side of the equation

AT THE END OF THE DAY,

LAST THOUGHTS: A SINGULAR OPPORTUNITY

IT IS ALWAYS ABOUT THE PATIENT.