Patient safety through physical design typically steers any discussion to the well-published areas of infections, patient falls, and staff injury. Of course, these areas are vital to safe care delivery. Infections originating from ventilation systems or hand washing non-compliance; patient falls owing to (yet to be robustly examined for empirical evidence) improper furniture, flooring, and a host of other hypothesized physical environment attributes; or staff injury arising from ergonomic factors, and thereby compromising safety, constitute prominent examples of direct impact of the physical design on safe care delivery.
However, let’s take a second look at some of these factors. Is hand washing compliance a physical design factor alone, or for that matter reducing patient falls? The answer is negative. In a majority of scenarios, safe care results from the joint impact of care processes and physical design, which interact in complex and meaningful ways – the higher the optimization of the interacting effects of the two domains the safer the care delivery.
This new perspective is certainly not a ground-breaking invention. So far, the two domains have examined the concept of patient safety independently, within their own silos. As a result, both domains developed independent check lists for safety that do not communicate with each other. For a majority of us safety was perceived as an issue solely residing within the domain of clinical practice (which is not incorrect, but ignores the critical influence of the interactions between clinical practice and the physical environment).
It was not until recently that the role of the physical environment in effecting safe clinical practice came to the fore. These studies were not conducted by design researchers. Rather, the evidence was forthcoming from clinical researchers. The first study that we came across was one conducted by a team at Stanford and Harvard. The objective of their study was to identify and isolate the top factors affecting patient safety from a frontline staff perspective. Of the numerous factors that ended up on their list from a representative sample of US hospitals, physical design (more specifically the layout) shared the very top slot. In the following years clinical publications emerged from such places as Columbia University College of Physicians and Surgeons that highlighted the critical role that (specifically) ‘visibility’ plays in ensuring safe clinical practice – in these cases visibility was linked to patient mortality.
There are two types of visibility – one between staff (peer-to-peer) and one between staff and patient. Why is visibility a critical factor in these days of electronic communication? Especially, in a culture where children are born with electronic gadgets, so to say, in hand, can’t technology (another vital domain to be considered simultaneously) offer appropriate solutions?
The answer seems to be negative. In 2006 the first author initiated a study at HKS Architects with the objective to understand what flexibility means to stakeholders in clinical practice, and the attributes of physical design and planning that are critical to maintaining short and long term operational efficiency. The study involved six large hospital systems across the United States. The focus was not on safety, but rather on efficiency and operational flexibility. Two factors emerged that are of interest to this discussion – peer-to-peer visibility, and staff-to-patient visibility. We dug deeper into these issues, since the question of technology support for visibility/communication needed to be examined in view of the findings. We found that technology does help and has provided tremendous support to the care givers, but has not (in its current state of development) replaced the need for direct visibility.
This raises two points of significance. First, efficiency and safety seem to be affected by the same attributes of the physical environment. Clinical literature suggests that from the perspective of clinical practice safety and efficiency are conflicting objectives – enhancing safety reduces efficiency of operations. Interestingly, from a physical design perspective, it appears that efficiency and safety go hand in hand.
In 2010, as the executive director of the Center for Advanced Design Research & Evaluation (CADRE), the first author initiated a study to explore and identify physical design correlates of safe and efficient care in hospital emergency departments. While developing the research protocol, we were extremely careful not to mix up the concepts of safety and efficiency – we wanted to have two separate lists of physical attributes, one for safety and one for efficiency. On study conclusion, what we ended up with was a single list. Every physical design factor that was identified as an efficiency issue was also impacting safety and vice versa; as if the two were Siamese twins. Even security (which is a slightly different concept) emerged as an issue affecting both. And, of course, at the top of the list was ‘visibility’ – a factor residing purely and solely within the physical domain, but bearing significant impact on safe and efficient clinical practice. Unfortunately, this column is too short to discuss the other attributes of the physical environment that affect safe care delivery, or even to examine visibility in greater detail.
This brings us to the second point of interest. Designing the physical environment to optimize visibility is not a trivial issue – ask any healthcare planner or designer. Moreover, optimizing on this one front could affect other critical areas (that we haven’t addressed here). It needs careful and concerted efforts in tandem by the design team, clinicians, the technology team, and the finance team – an aspect of the design process that owners and developers of healthcare facilities should take seriously. Incorporating HEPA filters or providing handrails only scratches the surface of substantially more rewarding areas that lie beneath.
But, as the first author mentioned in a Brazilian magazine (Saude Business) some time back, safety is not a black and white concept. It is a function of the level of risk acceptable to a specific culture. The key concept is the definition of ‘risk acceptability’. As a result, designing for safety could adopt different strategies depending on the cultural context, in addition to legal and financial constraints. However, if the patients (customers) are from a different culture (such as with medical tourism), it may be prudent to adopt risk acceptance prevalent in the context of the customers’ culture.In such a scenario, it is important not to copy-paste physical design solutions developed in other cultures, as operational cultures as well as process optimization.
Debajyoti Pati, PhD, FIIA, IDEC, LEED AP,
