In late
February 2013, Kerry Snell and I attended the International Quality and
Productivity Centre’s Health Facilities Design and Development Conference in
Sydney. The conference discussed the
challenges of creating health facilities to meet future demands on the sector
from the perspective of project managers, construction firms and academics.
The
conference opened with the keynote presentation via Skype from Professor CraigZimring of the Georgia Institute of Technology.
Professor Zimring discussed the development of evidence based design and
its implementation in the US context.
Studies quoted by Professor Zimring noted that US hospitals are
unnecessarily dangerous, with one in twenty patients contracting a healthcare
acquired infection.
Zimring
stressed the importance of evidence based design as a clinical tool that can
improve the quality and safety of the hospital experience, and provided a
number of examples where this can proven to be the case. Curtains used in the hospital context have
been linked to outbreaks of infection, leading to exploration of other options,
such as antimicrobial fabrics, blinds that are controlled electronically and
not touched by staff; and electrostatic opaque glass.
In addition,
the rising levels of hospital noise – generated from increasing equipment
noise, staff discussions and hard surfaces, among other factors – were shown to
have detrimental impacts on patient recovery.
Excessive noise, i.e. noise of over 35 decibels, can cause ventricular
arrhythmias, disrupt sleep, elevate heart rate, increase the need for pain
medication, decelerate wound healing, alter gastric myoelectrical activity and
autonomic nervous function. To mitigate
the effects of noise, it is necessary to have soft surfaces (which meet
infection control requirements), a reduction in public address announcements,
enclose sources of noise such as equipment and require staff to speak softer
and in designated areas.
Lighting and
visibility also impact on the length of patient stay and mortality rate. Studies found that the death rate of
particular patients was 70% higher in darker rooms, while another study found
that other patients stayed one day less in sunny rooms and required 22% less
pain medication. Lack of patient room
visibility by nurses resulted in a 30% higher mortality rate for high acuity
patients in a cardiac ICU ward. There
was also a 31% higher fall rate in low visibility rooms. Nurses need to be able to easily see each
other and their patients to effectively coordinate care.
Professor
Zimring noted some US examples of where evidence based design has made a
positive impact on patient outcomes – Fort Belvoir Community Hospital, where
recovery has been improved by the use of infection control compliant soft
panels to minimise noise and the use of single patient rooms; the Southcentral Foundation, an Alaskan
native operated health service, where employees have no private offices and
care is delivered in a multidisciplinary team approach; and the Dublin
Methodist Hospital, which has employed decentralised nurses’ stations,
hand washing sinks on entry to encourage compliance and single rooms with a
uniform configuration of equipment to facilitate treatment.
Professor
Zimring emphasised the need for continuous learning and quality improvement
through evidence, simulation and “systemness”, as well as a focus on patient
experience and empowering patients to take up a role in their own care.
Tony
Michele, the Project Director for the Victorian Comprehensive Cancer Centre
(VCCC) spoke about this new project. The
VCCC has three objectives: to reduce the cancer burden by 2029, to establish a
world class centre of excellence in cancer (increase percentage of patients
participating in clinical trials to 15%), and to increase investment in
biomedical research. The VCCC is first
and foremost a medical research facility, but it does have 100 inpatient beds. In terms of project management there were 2
deliverables: the creation of a
collaborative entity and the development of a purpose built facility.
Aladin Niazmand, the Director of Health Projects International (HPI), spoke about the role
of modular design in increasing flexibility and reducing costs and building
construction times. Modular and
prefabricated designs have become cheaper and more efficient every year for two
decades. There is currently incredible
variety and functionality in modular design options. HPI has produced a mobile app of
International Health Facility Guidelines which allows for departmental planning
on an industrial scale, 3D modelling and room layout sheets generated from
models. Prefabricated hospital
construction is innovative and is not “boxy”.
One third of construction can be completed in a day using prefabricated
materials.
David Walker
, Executive Director of the New Bendigo Hospital Project spoke about the
challenges of constructing a new regional hospital on an existing site. The existing Bendigo Hospital has been on the
same site since the 1850s, and much of the land around it is protected by
heritage listing, making permission to work on it difficult to obtain. It is the only public hospital in Bendigo and
is a teaching and regional referral hospital.
The site is split across a number of roads, and some services are spread
out across Bendigo – the thinking is to bring services like Mental Health into
an integrated facility to help reduce stigma.
$630 million has been estimated for the redevelopment of the hospital. Patient wayfinding has historically been an
issue. The website is the main
communication tool and receives 42000 hits per week. Projects, MOCs and sketch plans are available
online. Four information sessions are
held each year, with attendance figures ranging from 40-200 people.
Ronald Hicks, Principal and Head of Health + Research at
consulting firm Rice Daubney, spoke about the challenges of the integrated
cancer centre (ICC) concept in an Australian context. The ICC
concept finds its origins in the US during the 1970s, though there has been
marked development of the concept since then.
In the Australian
context there is a diverse approach to service with varying degrees of
integration. Some of the design
challenges of ICCs are the requirements for broad levels of consultation and
interaction. Traditional stakeholder
interactions involves speaking with clinicians; ICCs mandate interaction with service
users, the consumers/patients/families.
Both experience- and
evidence-based design should be incorporated into design and planning. It is also important to note that not every
part of the facility is/should be ruled by clinicians. Hicks also advocated an integrated approach
to parallel therapies. There also needs
to be an appetite for innovation. Two
examples noted by Hicks were the Prince of Wales Comprehensive Cancer Centreand the Chris O’Brien Lifehouse at RPA.
Trisha Ansell, the Project Manager at Barwon Health,
presented on the complexities of decanting a complex health facility, namely
the Barwon Health Children’s Ward. The
old ward contained mostly shared rooms and bathrooms, which posed significant
infection control concerns. There were
limited staff and parent facilities.
Treatment rooms were also used for storage. A new ward was constructed within a fully
operation hospital. Some of the
challenges were:
o
architects with limited experience in health
o
access for builders and construction noise
o
infection control
o
interruption to services
o
temporary accommodation required
o
reduced number of beds.
Barwon Health chose a local architect so that they could be familiarised
with the hospital so that they could be called on assist later with smaller
projects. The transportation of materials
and waste to and from the building site was also an issue. These, and other, challenges were managed
through a comprehensive decanting process.
The new ward contains dedicated spaces for parents and staff, including
a kitchenette, lounge, TV, washing machine and bathroom; more space for cancer
patients, negating the need for travel to Melbourne; single or double rooms; a
playroom; and a staff base made from glass, allowing noise to be decreased but
for staff to be visible. Ansell’s final
message about managing these kinds of projects was to “under-promise and
over-deliver”.
Heather McGowan.
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