Evidence-Based Hospital Design - First, do no harm

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Throughout their lifecycle hospitals contribute significantly to patients’ illness and wellness and to the human experience of staff, patients and families. This recognition is now driving hospital design to evolve far beyond the generic boxes of old and to become healing environments which positively influence clinical outcomes.

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Person-centred care revolves around enabling the relationship between patients and carer, and anything which distracts from or disrupts this relationship impacts directly on patient outcomes. Consequently, the built environment has the potential to help or hinder that relationship and to affect how care is delivered.
When designing a hospital it is easy to be distracted by the sheer scale and numbers of the macro environment, but it is in creating the right micro environment that the buildings core purpose is established and honoured; that is to enable the safe delivery of person-centred care.
Governance
Every hospital design innovation has the potential to change the model of clinical care and if not addressed during the design and commissioning process, also has the potential for great harm. Clinical governance and service re-design considerations should be introduced to the design process as early as possible.
Safe design process involves detailed mapping of the 7 flows of healthcare; patients, staff, medications, supplies, equipment, information and waste. This process allows for the pre-emptive examination of care paradigms and the mitigation of clinical risk. Opening a hospital and expecting staff to simply adapt existing care models on-the-run is not only dangerous but will also sap the staff’s engagement with their new hospital.
I give you the example of two affiliated hospitals, built across the road from each other. Naturally enough, the architects designed two large bridges to join the two partners and the service provision model was designed to share patients, staff and some operations. One of the operational decisions made was that after-hours surgery should only be performed on one campus; a logical approach. But what hadn’t initially been worked through were the various governance issues this raised.
So in the context of a clinical scenario where Patient A was being wheeled across the bridge at 10pm for an emergency bowel resection, questions were suddenly being asked: Are the surgical staff cross-credentialed to allow them to assess a patient across the road? Which consent form should they use? If Patient A has had blood crossmatched at one institution was this valid when they needed the blood administered in the other institution? Could we dispense drugs from one hospital’s medication chart at the other institution?
And so the questions continued to mount. If left unexplored, it is in these clinical decisions made reactively when patient and staff risk is created.
Engaging Clinical Staff
Workforce considerations are vital to an effective hospital design process. Great hospitals design decreases staff turnover and increases staff engagement with their patients and their organisation. A physical environment which enables best care will inspire staff and improve patient experience, creating a cycle of positive feedback and reinforcement.
Traditionally, architects build hospitals and clinicians and patients are expected to adapt. As a clinician I have never been asked to be a part of hospital design process. At best, I might be included in a focus group or see blueprints on the wall of an operating theatre. This leads to the same frustrating list of clinical obstacles and risks being reproduced in hospitals time and time again.
Once construction has commenced, it is rare for the clinicians to have any input into schedules or plans. I have been in midoperation before when a sudden stream of building noise and dust invaded my theatre with little regard for my patient or my schedule. With a little involvement, I could have made a decision regarding rescheduling or decanting my patient to accommodate construction.
The first I knew about a major concrete pour that was happening in the floor above me was when I was half-way through sewing a patient’s 2mm coronary artery and I heard a sonic boom which shook me and my operating table to its core. This began repeating every 5 seconds grinding my surgery to a halt. It was the day of the big concrete pour on the floor above and unbeknownst to me the pipe passed across the roof of my theatre.
With my patient on heart-lung bypass, I began sending desperate messages down to the pump operator. I was told the pump could not be stopped because the concrete would harden and I responded, somewhat peevishly, I admit, that it was going to be “hard concrete or dead patient.” With all the dust being shaken from the rafters there was also a real risk of the patient developing a deep sternal wound infection which carries with it a 50% risk of mortality and will cost the health service hundreds of thousands of dollars.
Situations such as these are common in live-build sites in hospitals and can often be avoided by the simplest of conversations with the right clinicians.
A co-design process that engages and constantly checks-in with hospital personnel, clinicians and patients should be the norm. Surgeons, junior doctors and nursing staff are vital in ensuring a hospital build or refurbishment is functional, sustainable and right the first time.
Identify clinical leaders who are motivated and invested. Speak with junior staff, many of whom these days are completely offay with technology solutions and know the infrastructure of the hospital intimately.
Spend time and immerse yourself in the hospital culture to find out what the staff need from their new theatres and wards; it will go far beyond the obvious. Find out what is going on in their current space and gather ideas. Medical staff have often worked in different hospitals and are a wonderful source of information and ideas; many have experienced poor design and can identify problems early on in the design process.
Poor physical environments and the scarcity of resources breed resentment amongst staff and can undermine patient care. Therefore the increased productivity and engagement of staff who feel welcomed in their new environment and better yet, feel ownership of it, cannot be underestimated.
Commissioning
Commissioning is an excellent way to engage clinicians in the build process and to ensure that clinical models are evaluated, amended and embedded before the opening ceremony.
Questions about different patient cohorts and models of care should be answered by clinicians rather than hospital executives and can influence everything from the size and configuration of the Intensive Care Unit to the location of the operating theatre lights. Clinicians are keen to share their insights about patient care and can help to co-create the best clinical environment for their particular patients.
Primum Non Nocere or first do no harm is a central tenet of medicine and it is imperative that our physical environment should reflect this notion. We must draw on both the design and clinical worlds to create hospitals which become active contributors to the health and wellness of our staff and patients.

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“A co-design process that engages and constantly checks-in with hospital personnel, clinicians and patients, should be the norm.”

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FAST FACTS

• Hospital design is evolving and hospitals are being built with the right micro environment in mind to enable the safe delivery of person-centred care.


• Safe design process involves detailed mapping of the 7 flows of healthcare; patients, staff, medications, supplies, equipment, information and waste.


• A co-design process that engages and constantly checks-in with hospital personnel, clinicians and patients should be the norm.


• Identify clinical leaders who are motivated and invested.


• Medical staff are a source of information and ideas; many have experienced poor design and can identify problems early on in the design process.


• Commissioning is an excellent way to engage clinicians in the build process and to ensure that clinical models are evaluated, amended and embedded before the opening ceremony.

Dr Victoria Atkinson is a cardiothoracic surgeon and the Chief Medical Officer and Group General Manager Clinical Governance at St Vincent’s Health Australia. Victoria also has EDAC certification in evidence-based design from the Center for Healthcare Design and is interested in the role of hospital design in influencing measurable clinical outcomes.