Clinic Design for Safety During the Pandemic: Safety or Teamwork, Can We Only Pick One?

OBJECTIVE: This article aims to illustrate the design considerations of team-based primary care clinics in response to the pandemic. BACKGROUND: Due to COVID-19, physical distancing became a critical practice in our daily life, especially in healthcare settings where healthcare professionals must continue providing care to patients despite the manifold risks. Many healthcare facilities are implementing physical distancing in their clinic layouts, and healthcare professionals are adjusting their behaviors, so they can stay away from each other. METHODS: A total of four team-based primary care clinics were studied to identify their lessons learned regarding safety measures and space usage during the pandemic. RESULTS: The four team-based primary care clinics made changes to the clinic design (e.g., waiting areas, exam rooms, team workspaces), operational protocols (e.g., in-person huddles, social gatherings, staff work locations), and usage of spaces (e.g., outdoor spaces, utility rooms). Such changes enabled the implementation of safety measures during the pandemic. However, healthcare professionals also reported challenges regarding their team communication and coordination due to physical distancing and separation. CONCLUSIONS: Our findings suggest that the physical distancing may in fact contribute to less effective teamwork and patient care and negatively affect staff well-being. In this article, we ask healthcare system leaders and designers to continue supporting both safety and teamwork by paying attention to the flexibility and spatial relationships among healthcare professionals rather than fully sacrificing teamwork for safety. Also, now is the time when multidisciplinary collaborations are needed to establish and validate guidelines that can improve both factors.

Examining the Relationship Between Environmental Factors and Inpatient Hospital Falls: Protocol for a Mixed Methods Study.

BACKGROUND: Patient falls are the most common adverse events reported in hospitals. Although it is well understood that the physical hospital environment contributes to nearly 40% of severe or fatal hospital falls, there are significant gaps in the knowledge about the relationship between inpatient unit design and fall rates. The few studies that have examined unit design have been conducted in a single hospital (non-Veterans Health Administration [VHA]) or a small number of inpatient units, limiting generalizability. The goal of this study is to identify unit design factors contributing to inpatient falls in the VHA. OBJECTIVE: The first aim of the study is to investigate frontline and management perceptions of and experiences with veteran falls as they pertain to inpatient environmental factors. An iterative rapid assessment process will be used to analyze the data. Interview findings will directly inform the development of an environmental assessment survey to be conducted as part of aim 2 and to contribute to interpretation of aim 2. The second aim of this study is to quantify unit design factors and compare spatial and environmental factors of units with higher- versus lower-than-expected fall rates. METHODS: We will first conduct walk-through interviews with facility personnel in 10 medical/surgical units at 3 VHA medical centers to identify environmental fall risk factors. Data will be used to finalize an environmental assessment survey for nurse managers and facilities managers. We will then use fall data from the VA Inpatient Evaluation Center and patient data from additional sources to identify 50 medical/surgical nursing units with higher- and lower-than-expected fall rates. We will measure spatial factors by analyzing computer-aided design files of unit floorplans and environmental factors from the environmental assessment survey. Statistical tests will be performed to identify design factors that distinguish high and low outliers. RESULTS: The VA Health Services Research and Development Service approved funding for the study. The research protocol was approved by institutional review boards and VA research committees at both sites. Data collection started in February 2018. Results of the data analysis are expected by February 2022. Data collection and analysis was completed for aim 1 with a manuscript of results in progress. For aim 2, the medical/surgical units were categorized into higher- and lower-than-expected fall categories, the environmental assessment surveys were distributed to facility managers and nurse managers. Data to measure spatial characteristics are being compiled. CONCLUSIONS: To our knowledge, this study is the first to objectively identify spatial risks for falls in hospitals within in a large multihospital system. Findings can contribute to evidence-based design guidelines for hospitals such as those of the Facility Guidelines Institute and the Department of Veterans Affairs. The metrics for characterizing spatial features are quantitative indices that could be incorporated in larger scale contextual studies examining contributors to falls, which to date often exclude physical environmental factors at the unit level. Space syntax measures could be used as physical environmental factors in future research examining a range of contextual factors-social, personal, organizational, and environmental-that contribute to patient falls. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24974.

Field Investigation of Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Pilot Study.

The Department of Veterans Affairs (VA) has developed a new exam room design standard that is intended to facilitate a greater degree of patient centeredness. This new design includes a wall-mounted monitor on an armature system and a moveable table workspace. To date, however, this design has not been formally evaluated in a field setting. We conducted observations and interviews with primary care providers and their patients from three locations within the Phoenix VA Health Care System, in a pilot study comparing the new exam room design standard with the older legacy exam rooms. When using the new exam room layout, providers spent a greater proportion of time focused on the patient, spent more time in screen-sharing activities with the patient, and had a higher degree of self-reported situation awareness. However, the legacy exam rooms were perceived as better facilitating workflow integration. Provider and patient debrief interviews were supportive of the new exam room design. Overall, our field study results suggest that the new exam room design does contribute to a greater degree of patient centeredness, though more thorough evaluations are required to support these preliminary results.

Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Laboratory Simulation Study.

BACKGROUND: Challenges persist regarding how to integrate computing effectively into the exam room, while maintaining patient-centered care. PURPOSE: Our objective was to evaluate a new exam room design with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. METHODS: In a lab-based experiment, 28 providers used prototypes of the new and older "legacy" outpatient exam room layouts in a within-subject comparison using simulated patient encounters. We measured efficiency, errors, workload, patient-centeredness (proportion of time the provider was focused on the patient), amount of screen sharing with the patient, workflow integration, and provider situation awareness. RESULTS: There were no statistically significant differences between the exam room layouts for efficiency, errors, or time spent focused on the patient. However, when using the new layout providers spent 75% more time in screen sharing activities with the patient, had 31% lower workload, and gave higher ratings for situation awareness (14%) and workflow integration (17%). CONCLUSIONS: Providers seemed to be unwilling to compromise their focus on the patient when the computer was in a fixed position in the corner of the room and, as a result, experienced greater workload, lower situation awareness, and poorer workflow integration when using the old "legacy" layout. A thoughtful design of the exam room with respect to the computing may positively impact providers' workload, situation awareness, time spent in screen sharing activities, and workflow integration.