Spatial Influences on Team Awareness and Communication in Two Outpatient Clinics: a Multiple Methods Study.

BACKGROUND: Healthcare organizations are moving their primary care teams out of private offices into shared workspaces for many reasons, including teamwork improvement and cost reduction. OBJECTIVE: Identify the specific aspects of layout and design that enable two fundamental processes of high-functioning teams: communication and situation awareness. DESIGN: This was a multi-method study employing qualitative interviews, floor plan analysis, observations, behavior mapping, and surveys. PARTICIPANTS: Two primary care clinics in a large, integrated healthcare system in the upper Midwest, with Clinic S in a suburban location and Clinic A in a rural setting. In the two clinics, a total of 36 staff members were interviewed, 57 (66% response rate) staff members were surveyed, and 2013 individual-points were recorded during 63 behavior mapping observations. MAIN MEASURES: Communication encounters, team members' perception of the environment and teamwork, visibility, distance, functional pathways, and self-reported mode and frequency of staff communication. KEY RESULTS: Observations, interviews, and surveys identified environmental factors that predict staff awareness and communication patterns. Visibility impacts situation awareness. Frequency of face-to-face communication increases with visibility and proximity between workstations (e.g., Clinic A nurses' intra-role communication without workstation proximity vs inter-role communication with workstation proximity: 22.6% [11.4, 33.9] vs 77.4% [66.1, 88.6], p = 0.001) and with staff members' functional paths. Visual exposure to patients predicts staff's concerns about their communication (Clinic S: 2.29 ± 0.81 vs Clinic A: 3.20 ± 0.84, p < 0.001). CONCLUSIONS: Design and layout of team spaces have important influences on the way that team members work together. The organizational goals of the healthcare system, particularly which staff members need to work together most frequently, should drive the specific design solution.

Design Strategies for Biocontainment Units to Reduce Risk During Doffing of High-level Personal Protective Equipment.

BACKGROUND: Few data exist to guide the physical design of biocontainment units, particularly the doffing area. This can impact the contamination risk of healthcare workers (HCWs) during doffing of personal protective equipment (PPE). METHODS: In phase I of our study, we analyzed simulations of a standard patient care task with 56 trained HCWs focusing on doffing of high-level PPE. In phase II, using a rapid cycle improvement approach, we tested different balance aids and redesigned doffing area layouts with 38 students. In phase III, we tested 1 redesigned layout with an additional 10 trained HCWs. We assessed the effectiveness of design changes on improving the HCW performance (measured by occurrence and number of risky behaviors) and reducing the physical and cognitive load by comparing the results from phase I and phase III. RESULTS: The physical load was highest when participants were removing their shoe covers without any balance aid; the use of a chair required the lowest physical effort, followed by horizontal and vertical grab bars. In the revised design (phase III), the overall performance of participants improved. There was a significant decrease in the number of HCW risky behaviors (P = .004); 5 risky behaviors were eliminated and 2 others increased. There was a significant decrease in physical load when removing disposable shoe covers (P = .04), and participants reported a similar workload in the redesigned doffing layout (P = .43). CONCLUSIONS: Through optimizing the design and layout of the doffing space, we reduced risky behaviors of HCWs during doffing of high-level PPE.

Understanding Experience of Patients With Highly Infectious Diseases During Extended Isolation: A Design Perspective.

OBJECTIVES: This study aimed to develop a better understanding of the unique needs of patients with highly infectious diseases and their perceptions of being placed in isolation. We explore the subjective experiences of patients treated for Ebola in a biocontainment unit (BCU) and the healthcare personnel who cared for them. BACKGROUND: The 2014 Ebola outbreak and the COVID-19 pandemic have brought to focus some major challenges of caring for patients with serious infectious diseases. Previous studies on BCU design have looked at ways to prevent self- and cross-contamination, but very few have examined how the built environment can support an improved patient experience. METHOD: A qualitative study was conducted with four patients treated for Ebola and two critical care nurses who provided direct care to them at a single BCU in the U.S. Data were collected through in-depth semi-structured interviews to capture the actual patients' perception and experience of isolation. The interviews were analyzed using the thematic analysis approach. RESULTS: The Ebola patients placed in source isolation perceived the BCU as an artificial environment where they lacked control, agency, autonomy, and independence. The physical separation from other patients, visitor restrictions, and staff wearing PPE contributed to feelings of social and emotional isolation, and loneliness. CONCLUSIONS: The isolation can take a toll on physiological and psychological well-being. A thoughtful design of isolation units may improve patients' experience by supporting human and social interactions, empowering patients through space flexibility and personalization of space, and supporting a more holistic approach to isolation care.

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.

Healthcare design to improve safe doffing of personal protective equipment for care of patients with COVID-19.

OBJECTIVE: Understand how the built environment can affect safety and efficiency outcomes during doffing of personal protective equipment (PPE) in the context of coronavirus disease 2019 (COVID-19) patient care. STUDY DESIGN: We conducted (1) field observations and surveys administered to healthcare workers (HCWs) performing PPE doffing, (2) focus groups with HCWs and infection prevention experts, and (3) a with healthcare design experts. SETTINGS: This study was conducted in 4 inpatient units treating patients with COVID-19, in 3 hospitals of a single healthcare system. PARTICIPANTS: The study included 24 nurses, 2 physicians, 1 respiratory therapist, and 2 infection preventionists. RESULTS: The doffing task sequence and the layout of doffing spaces varied considerably across sites, with field observations showing most doffing tasks occurring around the patient room door and PPE support stations. Behaviors perceived as most risky included touching contaminated items and inadequate hand hygiene. Doffing space layout and types of PPE storage and work surfaces were often associated with inadequate cleaning and improper storage of PPE. Focus groups and the design charrette provided insights on how design affording standardization, accessibility, and flexibility can support PPE doffing safety and efficiency in this context. CONCLUSIONS: There is a need to define, organize and standardize PPE doffing spaces in healthcare settings and to understand the environmental implications of COVID-19-specific issues related to supply shortage and staff workload. Low-effort and low-cost design adaptations of the layout and design of PPE doffing spaces may improve HCW safety and efficiency in existing healthcare facilities.

Developing a multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic review.

AIMS: This paper reports a review that assessed the effectiveness and characteristics of fall prevention interventions implemented in hospitals. A multi-systemic fall prevention model that establishes a practical framework was developed from the evidence. BACKGROUND: Falls occur through complex interactions between patient-related and environmental risk factors, suggesting a need for multifaceted fall prevention approaches that address both factors. DATA SOURCES: We searched Medline, CINAHL, PsycInfo and the Web of Science databases for references published between January 1990 and June 2009 and scrutinized secondary references from acquired papers. REVIEW METHODS: Due to the heterogeneity of interventions and populations, we conducted a quantitative systematic review without a meta-analysis and used a narrative summary to report findings. RESULTS: From the review, three distinct characteristics of fall prevention interventions emerged: (1) the physical environment, (2) the care process and culture and (3) technology. While clinically significant evidence shows the efficacy of environment-related interventions in reducing falls and fall-related injuries, the literature identified few hospitals that had introduced environment-related interventions in their multifaceted fall intervention strategies. CONCLUSION: Using the multi-systemic fall prevention model, hospitals should promote a practical strategy that benefits from the collective effects of the physical environment, the care process and culture and technology to prevent falls and fall-related injuries. By doing so, they can more effectively address the various risk factors for falling and therefore, prevent falls. Studies that test the proposed model need to be conducted to establish the efficacy of the model in practice.

The Representational Function of Clinic Design: Staff and Patient Perceptions of Teamwork.

OBJECTIVE: This study empirically investigates the relationships between visibility attributes and both patients' and staff members' teamwork experiences. BACKGROUND: Teamwork among healthcare professionals is critical for the safety and quality of patient care. While a patient-centered, team-based care approach is promoted in primary care clinics, little is known about how clinic layouts can support the teamwork experiences of staff and patients in team-based primary clinics. METHODS: This article measured teamwork perceptions of staff members and patients at four primary care clinics providing team-based care. Visual access to staff workstations from both staff and patient perspectives was analyzed using VisualPower tool(version 21). The relationships between teamwork perception and visibility attributes were analyzed for each entity: staff members and patients. RESULTS: The results showed that the visual relationships among staff members and those between staff members and patients have significant associations with overall perceptions of teamwork. While clinics providing more visual connections between staff workstations reported higher teamwork perception of staff members, patient perceptions of staff teamwork were inversely related to the number of visual connections between patients and staff workstations. CONCLUSIONS: The findings of the study provide implications for designing team-based primary care clinics to enhance the teamwork experience of both staff members and patients, which is also applicable to teamwork perceptions in other settings where both inhabitants and visitors are main user groups of the spaces. This study illustrates the representational function of space: Organizations can emphasize their values via layout design by regulating what they show to inhabitants or visitors.

Designing for Effective and Safe Multidisciplinary Primary Care Teamwork: Using the Time of COVID-19 as a Case Study.

Effective medical teamwork can improve the effectiveness and experience of care for staff and patients, including safety. Healthcare organizations, and especially primary care clinics, have sought to improve medical teamwork through improved layout and design, moving staff into shared multidisciplinary team rooms. While co-locating staff has been shown to increase communication, successful designs balance four teamwork needs: face-to-face communications; situational awareness; heads-down work; perception of teamness. However, precautions for COVID-19 make it more difficult to conduct face-to-face communications. In this paper we describe a model for understanding how layout affects these four teamwork needs and describe how the perception of teamwork by staff changed after COVID-19 precautions were put in place. Observations, interviews and two standard surveys were conducted in two primary care clinics before COVID-19 and again in 2021 after a year of precautions. In general, staff felt more isolated and found it more difficult to conduct brief consults, though these perceptions varied by role. RNs, who spent more time on the phone, found it convenient to work part time-from home, while medical assistants found it more difficult to find providers in the distanced clinics. These cases suggest some important considerations for future clinic designs, including greater physical transparency that also allow for physical separation and more spaces for informal communication that are distanced from workstations.

A Conceptual Visibility Framework for Linking Spatial Metrics With Experience and Organizational Outcomes.

Visibility enables or prohibits healthcare professionals' ability to monitor, control, or manage situations in healthcare settings. Visibility has a significant impact on patient safety, including patient fall rates and mortality rates, and on the performance of healthcare professionals, including situational awareness and communication. This article provides a conceptual visibility framework synthesizing visibility analysis models, tools, and metrics. The framework uses four dimensions that capture the experiential phenomena of users, such as visual relationships between specific sets of users/targets, how the orientation of the seeing entity changes visibility patterns, and the unequal visibility levels of seeing and being seen. The framework particularly focuses on how the layout and the resulting patterns of visibility reflect and influence the user experience and organizational functions. By illustrating the similarities and differences of various models in the framework according to the dimensions, this article describes how various visibility analysis models, tools, and metrics can be applied to design and research.

Backstage Staff Communication: The Effects of Different Levels of Visual Exposure to Patients.

OBJECTIVE: This article examines how visual exposure to patients predicts patient-related communication among staff members. BACKGROUND: Communication among healthcare professionals private from patients, or backstage communication, is critical for staff teamwork and patient care. While patients and visitors are a core group of users in healthcare settings, not much attention has been given to how patients' presence impacts staff communication. Furthermore, many healthcare facilities provide team spaces for improved staff teamwork, but the privacy levels of team areas significantly vary. METHOD: This article presents an empirical study of four team-based primary care clinics where staff communication and teamwork are important. Visual exposure levels of the clinics were analyzed, and their relationships to staff members' concerns for having backstage communication, including preferred and nonpreferred locations for backstage communication, were investigated. RESULTS: Staff members in clinics with less visual exposure to patients reported lower concerns about having backstage communication. Staff members preferred talking in team areas that were visually less exposed to patients in the clinic, but, within team areas, the level of visual exposure did not matter. On the other hand, staff members did not prefer talking in visually exposed areas such as corridors in the clinic and visually exposed areas within team spaces. CONCLUSIONS: Staff members preferred talking in team areas, and they did not prefer talking in visually exposed areas. These findings identified visually exposed team areas as a potentially uncomfortable environment, with a lack of agreement between staff members' preferences toward where they had patient-related communication.

Measuring Interpersonal Visual Relationships in Healthcare Facilities: The Agent Visibility Model and SAVisualPower Tool.

Visibility has a significant impact on health-related outcomes and experiences of users in healthcare settings. Built environments determine interpersonal visual relationships between users and control their ability to see (or be seen by) others. Despite this importance, metrics that fully and precisely describe these interpersonal visual relationships are lacking. In this article, we introduce the Agent Visibility Analysis Model and the SAVisualPower software, which enable person-centric visibility analysis for quantifying visual relationships both among users and between users and visual targets. The model precisely captures users' visibility by reflecting the orientation of users and by differentiating visual contents of the users-space, other users, and targets. By providing practical examples of the new model using layouts from previous studies, this article describes specific visibility metrics that can be analyzed by the new tool and how the tool can be applied to design and research in healthcare settings for improved user experiences.

Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.

OBJECTIVE: To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU). DESIGN: We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises. SETTING: The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup.ParticipantsA total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study. RESULTS: In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) and HCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCW adherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements. CONCLUSIONS: Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.

The role of the physical environment in crossing the quality chasm.

BACKGROUND: Evidence-based design findings are available to help inform hospital decision makers of opportunities for ensuring that quality and safety are designed into new and refurbished facilities. FRAMEWORK FOR THE EVIDENCE: The Institute of Medicine's six quality aims of patient centeredness, safety, effectiveness, efficiency, timeliness, and equity provide an organizing framework for introducing a representative portion of the evidence. Design improvements include single-bed and variable-acuity rooms; electronic access to medical records; greater accommodation for families and visitors; handrails to prevent patient falls; standardization (room layout, equipment, and supplies for improved efficiencies); improved work process flow to reduce delays and wait times; and better assessment of changing demographics, disease conditions, and community needs for appropriately targeted health care services. THE BUSINESS CASE: A recent analysis of the business case suggests that a slight, one-time incremental cost for ensuring safety and quality would be paid back in two to three years in the form of operational savings and increased revenues. Hospitals leaders anticipating new construction projects should take advantage of evidence-based design findings that have the potential of raising the quality of acute care for decades to come.