By Allen Foucht, BSN, RN, CLSSMBB
Today’s healthcare is complex and requires delivery systems that leverage evidence as they strive to produce the best outcomes. To succeed as top performers, healthcare organizations must ensure that the care delivery environment enables staff to keenly focus on patients—what is commonly known as patient-centered care. Unfortunately, even though many organizations use the Lean principle of involving frontline staff in projects, those who spend the most amount of time with patients are often not part of the design process. As a result, facilities are frequently designed in a manner that does not support optimal care or that could even lead to quality and safety issues.
Regrettably, I hear stories such as the following in all areas of the country: Nurses and staff are excited about relocating to a new environment. Unlike their old facility, which had ramps between hospital wings, semi-private rooms, and poor information systems, the new facility offers smoother transitions between wings, private rooms, and a beautiful environment with plenty of bright colors and natural light. It also has state-of-the-art information systems and locating methods. Unfortunately, after a few weeks of navigating the new facility, the staff realize that although it looks great, it is not designed for staff and patient efficiency. Soon, facility leaders find themselves once again having discussions about quality and communication—the same issues discussed at the old facility, issues that staff thought they were leaving behind.
For many years, the physical environment has been linked to reducing staff stress and fatigue, increasing effectiveness of care delivery, improving patient safety, boosting patient outcomes, and ensuring overall healthcare quality (Rubin, Owens, & Golden, 1998). In a 2008 study published in the Permanente Journal, authors found that nurses only spend 19.3% of their time on patient care (Hendrich, Chow, Skierczynski, & Lu, 2008). Personal studies have shown me that 80% of nursing time is not spent with patients. Of that amount, 40% is spent searching for people and equipment. These studies and many more tie the physical environment to staff and patient outcomes. If healthcare organizations can find ways to keep nurses in rooms with patients, we could support stable nurse-to-patient ratios. We could also decrease costly adverse outcomes such as falls, lower mortality rates, and improve nurse retention (Aiken et al., 2003).
I can recall many times, after going through an event investigation process, how it was clear that many patient safety issues could have been eliminated if a nursing or clinical perspective had been incorporated into design decisions (Carroll, 2014). One of the main reasons that the Agency for Healthcare Research and Quality (AHRQ) requires frontline staff on the core event investigation team is to help prevent adverse events (AHRQ, 2017). After these event investigation sessions, actions and processes are developed and put into place to help prevent recurrence. That’s why those who were involved in the event—generally frontline caregivers—should always play a role in the original design process as well as the resolution process. Doing so could prevent events not just from recurring, but from ever occurring at all.
Nurses have direct knowledge of patient care issues, and thus they should play a pivotal role in facility design. Moreover, of all the healthcare providers involved in patient care, nurses are likely the only ones that provide care 24/7. Even in the outpatient setting, it is more probable that nurses would be involved in many aspects of patient care.
Keeping this in mind, we know that Lean concepts are now a major component of the facility design process. The foundation of Lean, relative to healthcare, is the removal of waste to create efficient and effective patient care processes. This again points to the need for nurse involvement, to better understand patient flow as well as staff workflow.
Given our reliance on staff to improve processes, and given all the evidence that links the physical environment to staff, why are nurses and clinical staff not always involved in the design process? For many, the challenge and costs associated with taking nurses away from the bedside may seem too great in the moment. However, the cost of not involving frontline staff in design planning can be much greater and result in inefficient workflow, reduced productivity, poor adoption, negative perception by staff, and even adverse events.
Stichler (2016) mentions in Nursing’s Impact on Healthcare Facility Design, that years ago nurses were not included in the facility design process and were instead represented by administration. However, there are many reasons why nursing is now often included. For example, the Magnet® program requires nurses to be involved, active participants in changing the work environment and workflow (American Nurses Credentialing Center, 2017). Architects and evidence-based design offer knowledge on aspects that can be beneficial to patient care, and when teamed with clinicians, they can develop strategies and facility design to ensure the right care in the right place at the right time (Rutherford et al., 2017) and to help avoid patient harm or issues with care. Additionally, nurses are trained to understand and assess how the environment affects the healing process.
According to the AHRQ (2004), patients now require a higher level of care due to new technologies and decreasing length of stay. The time that nurses spend with patients can certainly add to that discussion. Armed with their knowledge of the facility’s patient care flow and the nurse-to-patient ratios on specific units, as well as the evidence-based practices they are likely involved in every day, nurses should give advice on how to design the flow of care based on their unique understanding of the entire care continuum.
Today’s healthcare environment calls for delivery systems that are evidence-based and focused on patients’ needs. The government is demanding a higher level of patient safety and quality of care through increased regulatory pressure, and consumers are also seeking out high-quality services. As a result, healthcare systems need to reinvent themselves to meet the needs of the future. To have a great facility, you must be able to identify the greatest priorities that the facility needs to fulfill for your organization. Nurses can be a valuable part of this facility design process.
Allen Foucht, BSN, RN, CLSSMBB, is a Lean consultant for Versus Technology, a workflow technology firm that uses real-time locating systems to improve the delivery of care. Using data, insight, experience, technology, and process, Foucht works with provider organizations to improve the patient experience and rethink patient flow.
Agency for Healthcare Research and Quality (2004). Hospital nurse staffing and quality of care. Research in Action, Issue 14. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html
Agency for Healthcare Research and Quality (2017, September). System-focused event investigation and analysis guide. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4-guide.html
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290(12), 1617–1623. doi:10.1001/jama.290.12.1617
American Nurses Credentialing Center (2017). ANCC Magnet Recognition Program. Retrieved from http://www.nursecredentialing.org/Magnet
Carroll, R. L. (2014). Enterprise risk management: A framework for success. Chicago, IL: American Society for Healthcare Risk Management.
Hendrich, A., Chow, M. P., Skierczynski, B. A., & Lu, Z. (2008). A 36-hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3), 25–34.
Rubin, H. R., Owens, A. J., & Golden, G. (1998). An investigation to determine whether the built environment affects patients’ medical outcomes. Martinez, CA: Center for Health Design.
Rutherford, P. A., Provost, L. P., Kotagal, U. R., Luther, K., & Anderson, A. (2017). Achieving hospital-wide patient flow. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Stichler, J. F. (2016). Patient safety: A priority for healthcare and for healthcare design. HERD: Health Environments Research & Design Journal, 9(4), 10–15.