Addressing the Quality and Safety Gap - Part III

The United States is in the midst of a major health care construction boom, with spending projected to exceed $60 billion by 2014. Nurses at all levels and in every setting have a critical role to play on multidisciplinary teams charged with assessing, planning, and designing new and replacement facilities. Evidence-based design (EBD) provides a framework for ensuring that decisions about layout, lighting, and other physical elements are grounded in research, and there is some evidence to suggest it also yields positive economic returns on investment through improvements in patient outcomes, staff effectiveness, and operational efficiency. This report, the third in a miniseries on quality and safety, discusses EBD as it relates to nursing practice, administration, and education and highlights the importance of alignment among architecture, information technology, clinical processes and workplace culture.

Over the last 10 years, spending on construction of health care facilities in the United States has doubled, driven by demographic changes, the need to replace outdated facilities, and a heightened focus on quality and safety. That trend is expected to continue over the next few years, with annual spending projected to exceed $60 billion by 2014. That construction wave is accompanied by a determined effort to make sure that, as architects say, “form follows function.” The latest entry in the Robert Wood Johnson Foundation’s (RWJF’s) Charting Nursing’s Future policy brief series maps out recent innovations in the field, and explains the vital role nurses are playing in redesigning facilities across the nation.

The brief, Addressing the Quality and Safety Gap—Part III: The Impact of the Built Environment on Patient Outcomes and the Role of Nurses in Designing Health Care Facilities, emphasizes that just as nurse-led innovations in care delivery are built on a strong foundation of research, new design approaches are also expected to be based in evidence.

The new brief notes that nurses are uniquely situated to provide input and feedback to hospital architects and designers. “Of all the health care professions, nursing is the backbone for what goes on in hospitals,” says Kerm Henriksen, Ph.D., human factors advisor for patient safety at the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality: “Nurses have a lot of practical knowledge and can help identify design threats to patient safety and quality of care, like having to dispense medications in high-traffic areas that invite interruption.” In addition, he notes, “They are aware of the other system components that have a daily impact on their activities and are accustomed to step­ping outside their silo—working with folks in pharmacy, for example—to address barriers to good patient care.”

Designing Spaces to Improve Care for the Military

For those reasons and others, many architects and health care administrators are bringing nurses into the planning process for new or designed spaces.

For example, in 2005, Congress overhauled the Department of Defense’s Military Health System (MHS), with the goal to improve the quality of care for active-duty military personnel. (MHS is separate from the Veterans Health Administration, which provides care for veterans.) Along the way, MHS adopted a set of principles that recognized the key role that physical design plays in patient outcomes and staff effectiveness.

Eileen B. Malone, R.N., M.S.N., M.S., E.D.A.C., senior partner at Mercury Healthcare Consulting, L.L.C., and former C.E.O. and commander emeritus of DeWitt Army Community Hospital at Fort Belvoir, served as a consultant to MHS during this process. “We have these wonderful stovepipes of innovation,” she explains, “but very little integration, because architects, I.T. [information technology] experts and clinicians tend to work in separate silos.” She developed a model for the military, subsequently refined for a broader application, that focuses on such common strategic goals as preventing falls, and provides a conceptual framework for examining the interplay among physical, technological and human factors, as well as the need for more multidisciplinary research. “Nurses have a very important role to play in this research,” she says.

Redesign, Post-Katrina

In New Orleans, Louisiana, the 2005 devastation of a public hospital by Hurricane Katrina created an opportunity to build nurse-informed design innovations into a replacement facility. Mary L. Kelly, R.N., M.S.N., M.H.A., clinical liaison to the planning team for the new Louisiana State University hospital, brought together groups of nurses, physicians and other staff to develop designs, addressing such issues as patient and family zones, standardized rooms, nurse travel times, patient visibility, controlled access, natural lighting, and more. In their planning, designers relied on research by experts from Georgia Tech’s College of Architecture, who pulled together evidence from the literature to inform their choices. This research was supported by RWJF.

Similarly, in central Ohio, Cheryl Herbert, R.N., M.B.A., F.A.C.H.E., E.D.A.C., oversaw the planning, design and construction of a new hospital built by OhioHealth. “Any place nurses would be working—the emergency department, maternity, the medical-surgical intensive care unit,” she says, “we made sure to include them in our advisory group for that area....Nurses were instrumental in designing patient rooms, including the headwalls behind the beds. We had budget constraints, of course, but we tried to use their input everywhere we could, especially when there was consensus about what to do.”

As a result, the newly built Dublin Methodist Hospital incorporates a number of evidence-based design features including single-bed patient rooms to reduce the risk of contagion, enhance privacy and support family involvement; hand-washing sinks in every patient room; acuity-adaptable surgical ICU rooms to cut down on the moving of patients as their conditions change; and more.

Other design choices that are being used more often across the country as a result of research and nurse input are highlighted in the brief as well. They include:

  • Ventilation and filtration systems to improve air quality and remove allergens, pathogens and more;
  • Ergonomically designed patient rooms, including patient lifts and handrails, as well as beds and nursing stations designed to reduce patient falls and staff injuries;
  • Decentralized unit layouts so as to increase the time nurses spend at the bedside;
  • Better lighting to ward off medical errors;
  • More natural sunlight, in part because studies show that it helps blunt the perception of pain, improves the quality of sleep and leads to shorter hospital stays, while allowing nurses to better assess skin tone;
  • Noise reduction features, such as carpet, acoustical tiles, handheld pagers as a substitute for overhead systems, to improve sleep and reduce stress;
  • Better way-finding systems, including maps, landmarks, signage, information kiosks, directories and more, to help patients and visitors while allowing staff to focus on their clinical duties instead of giving directions; and
  • Access to nature, water features and works of art, all to reduce stress.

Training the Next Generation

Another indication that nurses will be more involved in design choices in the future is the appearance of coursework in nursing schools that incorporates design issues. The brief highlights several institutions that have incorporated design into their curricula, including programs at Holy Names University in Oakland, California; Texas Woman’s University School of Nursing; and Arizona State University.

To view content after June 2017, visit Charting Nursing's Future at its new home on the Future of Nursing: Campaign for Action website.