Highlights: When a group of hospital planners set out six years ago to design a hospital where medical errors would not occur, they hoped the healthcare community could learn from the changes they made in design and construction. The hospital, in a Milwaukee suburb, opened nearly two years ago, and already it has received much attention in the medical press. Many of you may already have heard about the hospital, St. Joseph’s Hospital in West Bend. We are aware of some projects in Ohio where the design team has produced outstanding patient-centered designs, but for those of you who are not familiar with this hospital and its design process, we take this opportunity to provide you with this case study of a hospital that was designed expressly to minimize medical errors. We hope you will find this article informative and thought provoking.
Which causes more deaths each year, breast cancer, AIDS, auto accidents, or medical errors? If you said, “medical errors,” you may be familiar with the results of one report, “To Err Is Human: Building a Safer Health System,” the Institute of Medicine’s well-documented study that shook up the healthcare community in 2000. [While we do not vouch for the results of this study, we note that it has captured the attention of many in the medical community.] That study concluded that of the 33.6 million admissions to U.S. hospitals in 1997, at least 44,000 of them—and perhaps as many as 98,000 of them—resulted in death attributable to medical error. Even the lower estimate exceeded the total for auto accident deaths, 43,458. The totals for breast cancer and AIDS were smaller still.
The Institute of Medicine’s report recommended a four-tiered approach to the crisis, starting with a national focus on the problem and concluding in the “ultimate target”: the implementation of practices at the delivery level intended to promote the safety and health of patients and staff.
How could the problem of medical error be resolved, one hospital at a time? Could design changes in the way the building is laid out and finished really have an impact on patient safety? Spurred on by the findings in the Institute of Medicine’s report, one hospital set out to find the answers to these questions in 2001. Four years later, in August 2005, St. Joseph’s Hospital opened its new facility in West Bend, Wisconsin, becoming probably the first hospital anywhere designed specifically to eliminate medical error and infection, or to come as close as humanly possible.
The Case Study
The old St. Joseph’s, part of the SynergyHealth regional health network, had been around since 1930 and obviously needed a lot of updating. When plans for the new construction started taking shape in 2001, the Institute of Medicine report was still fresh in everyone’s mind. According to St. Joseph’s former CEO, John Reiling, the idea originated with a hospital administrator: Why not see what the new hospital could do to increase safety through its design?
By the time the hospital sent out Requests for Proposals to design professionals, safety was a major focus. Design professionals were asked to commit to working with the hospital staff to figure out how best to build a truly safe hospital facility. That process resulted in the selection of Gresham, Smith and Partners, an architectural firm from Nashville, Tennessee, to design the new facility, with Thomas Wallen, AIA, as the project architect.
Other team members came on board early, too. The general contractor, CG Schmidt, Inc., was a local company from Milwaukee, while Ric Miller Construction/ Consulting, LLC, of Colgate, Wisconsin, served as the owner’s representative.
All were committed to building an 80-bed, 180,000+ square-foot hospital for a project cost of about $55 million. But more important, all were committed to making it the world’s safest hospital.
Innovation: A “Learning Lab”
One early innovation in the design process was a “Learning Lab” that took place over two days in April 2002 and focused on patient safety. How could industrial safety techniques be applied in a healthcare setting? With support from the University of Minnesota’s Carlson School of Management, the hospital set out to answer that question. It brought together an interesting mix of viewpoints—experts from industry, aviation, systems engineering, behavior research, pharmacy, health care administration, hospital architecture and, of course, medicine. Even competitors from other regional health systems were included. The architects and contractors attended, too, to observe and participate.
In preparation for the Learning Lab, the hospital planners selected 10 “specific precarious hospital events” the hospital should be designed to avoid. The list came from two sources—the Sentinel Events Database of the Joint Commission on Accreditation of Healthcare Organizations and the Veterans Administration National Center for Patient Safety—and ranged from such commonplace events as patient falls and post-operative infections to rarer tragedies such as wrong-site surgeries, deaths of patients in restraints, and inpatient suicides.
Participants at the Learning Lab heard keynote speakers and then broke into workgroups to focus on these precarious events and develop recommendations for designing to avoid them.
Innovation: The Design Principles
The workgroup recommendations led to a six-page brochure summarizing a dozen Facility Design Principles that served as guideposts for the construction:
1. Visibility of patients to staff. Proper lighting, cameras, and a window between the charting alcove and the patient room make it possible for staff to see patients at all times. Increased visibility should cut down on falls as well as reduce incidents of suicides.
2. Standardization. Making the rooms identical was a big step in reducing human error. The traditional hospital employs “mirror image” rooms that share a headwall, so a gas supplied at the far left of one room will be supplied at the far right of the room next door. Not so at St. Joseph’s. Each 358-square-foot room is identical to the room next door, and to the room next to that. Even the light switches are in the same positions.
3. Automation, where possible. The hospital makes the most of new technologies to avoid depending on faulty human memories. Medicines are bar-coded and delivered in pneumatic tubes. Medical records are available electronically and can be accessed on a COW in every room. (What’s a COW? Well, the hospital is in Wisconsin, but this COW is a Computer-On- Wheels.)
4. Scalability and adaptability. The building had to be especially designed to accommodate future expansion and changes in technology and healthcare processes, avoiding obsolescence.
5. Immediate access to information at the point of service. The COWs are vitally important in carrying out this principle.
6. Noise reduction. The typical hospital room, even when vacant, measures 55 on the decibel rating scale, according to former CEO Reiling. At St. Joseph’s, this measurement is below 35 decibels. Sound-absorbing materials contribute to this achievement; even the superstructure includes low-vibration steel. And vibrating pagers substitute for the noisy paging system traditionally used. The advantage is two-fold: patients sleep better (thus healing more rapidly), and staff is less fatigued (avoiding many errors that result when caregivers are overtired).
7. Patient involvement in care. Spaces were designed to encourage family meetings, giving patients and their loved ones opportunities to ask questions about healthcare and become part of the decision-making team.
8. Minimizing fatigue. In addition to the noise reduction already mentioned, fatigue reduction measures include permitting staff to sit frequently and cutting down on travel distances needed to care for patients. Adjacencies were planned to reduce the steps it takes to get from the emergency room to radiology, for instance. Cutting 14 steps off that route can add up over the course of a week, or even a day. Uniform, proper lighting throughout the hospital also is designed to reduce fatigue as well as aid in accurate diagnoses.
9. Incorporating Failure Model Effects Analysis into each stage of the design process. Used for many years by engineers, FMEA studies the way things fail and the consequences of those failures. It is a proactive approach to evaluating how a failure will affect the user and how it can be prevented or mitigated. The analysis involves a flow diagram of the process and a failure “score” ranging from 1 (lowest) to 10 (highest) on each of three variables: severity, probability, and difficulty of detection. The three scores are then multiplied to determine a Risk Priority Number, with the highest going to a process whose failure would result in death (a 10 in severity), might occur frequently, and would be relatively difficult to detect or predict. Any process with a high Risk Priority Number must be addressed right away, with changes incorporated into the plans to reduce the overall score. The design team for St. Joseph’s used such an analysis in planning adjacencies, again at the schematic stage, and in design development.
10. Designing for vulnerable patients. Special attention to the movement of patients throughout the hospital always focused on planning for the most vulnerable members of the hospital population. Additionally, St. Joseph’s incorporated in all areas of the hospital the special air filtration systems normally found only in critical care units or operating rooms.
11. Reviewing human factors. How do changes in equipment, technological developments, and facility modifications affect human performance? Using human factors expertise, the hospital determined to standardize and simplify all aspects of the hospital environment.
12. Designing around precarious events. At each stage of the design, the design team tried to anticipate the ten specific precarious hospital events already identified and sought ways to come close to eliminating them.
Innovation: Putting Design Development Up Front
Armed with these 12 Design Principles, an 11-member Facility Design Advisory Council emerged from the Learning Lab ready to shake up the whole design process. One notable change was in the sequence of design decisions. To achieve the standardization necessary to avoid accidents, the design team had to do much of the design development phase work at a very early stage of the process—in the initial concept design phase.
Room mock-ups were built and rebuilt, with some even tested out in the old hospital before getting the seal of approval. At every stage, hospital staff had their say, even writing graffiti on the walls of the mock-ups to point out items that needed to change. The goal throughout was error- free care.
How did the shake-up in the usual design sequence affect the architectural process? Wallen, the project architect, noted that schematic design went more smoothly, with more accurate drawings available much sooner than is normally the case.
Innovation: The Details
Often, it is the little things that count. Window blinds sealed between the window panes rather than collecting dust. Sinks that can be seen from the patient’s bed, and programs to promote hand washing. Handrails leading from a patient’s bed to the bathroom a few steps away. Sensors that turn on bathroom lights automatically when a patient enters—helping to prevent falls, yes, but also making it unnecessary to touch a light switch, a possible source of infection.
Making the hospital safer for the patients also involves making it safer for the staff, of course. A rested, healthy staff commits fewer errors. To avoid the common problem of back injuries, the hospital designed each room to include a battery-powered patient lift. Nurses no longer have to struggle to move an inert patient from the bed to the chair but can use a sling and a hoist instead.
In August of 2005, the facility opened—on time, it should be noted. Did all of these safety measures ultimately make the project cost more? Apparently not. Even the departure from the standard mirror-image rooms—which were originally planned as a cost-cutting measure—turned out to be less expensive than many had feared. Mike Murphy, vice president of patient care services, explained the reason in an article in Health Facilities Management: “What it costs in having the unique headwall for each bed, you save in being able to prefab more things off-site rather than having to custom make everything on-site.”
So standardization turned out to reduce cost while it improved quality—just as it has in other industries. But has it reduced accidents, medical errors, and infections, as the planning team hoped? The answers to that question will be coming in for some time, as the hospital continues to operate under a magnifying glass. (Some have called St. Joseph’s the most-analyzed 80-bed community hospital in America.)
More than a year after the opening, it is apparent that many of the design features have proven successful in achieving the desired objectives, says Michael Murphy, Vice President of Administration and Chief Nursing Officer. Key adjacencies have been shown to have a positive impact on operations and patient care.
As is readily apparent when walking on to the Med/ Surg Unit, noise has been significantly reduced, but statistical evidence is just being gathered now for the comparative analysis between the old hospital and the new. The hospital hopes to answer other questions, too, about how technology affects patient safety. Using a $1.5 million grant from the Agency for Healthcare Research and Quality, it is in the middle of a three-year study, with results due early next year.
One thing is clear in the 22 months that the hospital has been operating so far: The emphasis on safety in the construction phases has moved it to the forefront in everyone’s mind, leading to a culture of safety throughout the hospital.
Can St. Joseph’s Be Replicated?
No one would suggest that hospitals are fungible products that can be mass-produced and shipped off to various parts of the world for installation. Each one is a product of its community, its setting, and the special needs it must fulfill. But much can be learned from the St. Joseph experience, and there is much to emulate.
Would a hospital that wanted to follow in St. Joseph’s footsteps need to make many contractual changes? Probably not. The most notable would be in the planning stages, as the commitment to safety appeared even in the Requests for Proposals that went to the design professionals. Getting everybody involved early on and participating in the Learning Lab was important, so that process had to be incorporated into the contracts.
Couldn’t another hospital skip the Learning Lab step and just copy the 12 Design Principles wholesale from the work already done by St. Joseph’s? Maybe, but it is not likely that the results would be the same. A hospital that wants to achieve a “culture of safety” is unlikely to succeed if it merely imposes one from the top. St. Joseph’s developed its culture from three years of intensely focusing on a common goal—as the website for the architect, Gresham, Smith and Partners, puts it, “the world’s safest hospital . . . an environment that compels caregivers to provide errorfree care.”
But St. Joseph’s had another goal, too. The hospital team wanted to serve as a model for others to learn how facility design can impact patient safety. If St. Joseph’s is to achieve this goal, it must be copied. It must become not “the world’s safest hospital,” but only one of many “safest hospitals,” all focusing on one goal: seeing to it that medical errors are no longer one of the leading causes of death in America.