Evidence-Based Design: Inova Fairfax Hospital's Journey (Text Version

---

On September 16, 2009, Reuven Pasternak made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (2.1 MB).

---

Slide 1

Evidence-Based Design: Inova Fairfax Hospital's Journey

Reuven Pasternak, MD
Chief Executive Officer
Inova Fairfax Hospital Campus
Executive Vice President for Academic Affairs
Inova Health System
Falls Church, VA

Slide 2

Evidence-Based Design: Inova Fairfax Hospital's Journey

• Objectives
  • At the conclusion of the presentation, the participant should be able to describe:
    1. 1. At least 3 ways Inova Fairfax Hospital is incorporating evidence-based design elements to enhance patient safety and quality of services delivered.
    2. 2. The impact of evidence-based design on clinicians.
    3. 3. The role of clinicians in planning the building to reflect evidence-based design.

Slide 3

Inova Fairfax Hospital: Unique Role in the Community

• 833 licensed beds + COPN for 43 obstetrical beds
• Only Level 1 Trauma Center in Northern Virginia
• Fourth highest birth rate in the United States
• Highest level of neonatal intensive care in Northern Virginia
• Only Obstetrics-Gynecology Clinic for disadvantaged expectant mothers in Fairfax County
• Only dedicated heart and vascular care hospital in the area
• Highest level of critical care, including organ transplants / neurosurgery
• Key provider of medical education and research

Slide 4

Inova Fairfax Hospital: Unique Service for the Community

• Named a HealthGrades America's 50 Best HospitalT for 2009
• One of only 6 nationally accredited Primary Stroke Centers in Virginia
• Received national Magnet Recognition for Excellence in Nursing Quality for the last 10 years
• One of five AA+ rated healthcare organizations in the country

Slide 5

The Need: Impetus to Begin a Journey

• Main patient care tower:
  • Over 40 years old
  • Lacks private rooms
  • Inadequate mechanical
  • and electrical systems
• Patient rooms are significantly undersized for current patient and family needs.

Slide 6

The Need: Impetus to Begin a Journey

• Unclear wayfinding (locating services)
• Women's services significantly outgrew the current facility capacity

Slide 7

The Need: Population Growth

MWCOG Round 7.1 cooperative forecast for entire region
	2005	2010	2015	2020	2025	2030	2005 to 2020	2005 to 2030
Fairfax	1,044	1,136	1,214	1,279	1,307	1,334	235.1	290.3
Fairfax City	22	24	25	26	26	27	3.5	4.4
Falls Church City	11	12	14	15	15	15	4.1	4.8
Fairfax/Falls Church - up 300K	1,076	1,171	1,253	1,319	1,347	1,376	242.7	300
Alexandria/Arlington - up 78K	335	360	377	392	403	414	56.8	78.4
Loudoun - up 221K	247	301	354	410	449	469	162.6	221.2
Prince William/Manassas - up 214K	400	469	519	549	582	614	148.9	213.8
	2,059	2,302	2,504	2,670	2,781	2,872	611	812.9

Slide 8

The Need: Aging Population

0-17	18-44	45-64	65+
182637	239009	153920	237334

Slide 9

The Need: Demand for Obstetrics

OB Deliveries at Inova Fairfax Hospital 1986-2030 (projected)

1986	2006	2020	2030
7899	11744	13000	14500

Slide 10

What is Evidence-Based Design (EBD)?

Center for Health Design (CHD) defines EBD as:

"The deliberate attempt to base building decisions on the best available research evidence with the goal of improving outcomes and of continuing to monitor the success or failure for subsequent decision-making."

(Ulrich et. al. 2004)

Slide 11

Inova Health System: Mission, Vision, Beliefs

Excellence in health care, education and research

P A T I E N T C E N T E R E D C A R E

• QUALITY
• SERVICE
• COST
• PEOPLE
• GROWTH
• COMMUNITY

CONTINUOUS QUALITY IMPROVEMENT

VISION - BELIEFS

MISSION - COMMITMENTS

M I S S I O N
To improve the health of the diverse community we serve through excellence in patient care, education and research.

V I S I O N
To be the best health care system in the world.

B E L I E F S
Trust. Respect. Compassion. Empowerment. Integrity. Partnership. Quality. Value.

O U R C O M M I T M E N T S
Innovative Excellence. Caring about People. Community.

Slide 12

Image: Evidence-Based Design Elements: Linkage to Pillars

Slide 13

Image: Schematic Design Exterior Concepts

Slide 14

Evidence-Based Design: The Journey with Eyes Wide Open

• Effects of healthcare environmental design on medical outcomes
  • What does the literature reveal?

Slide 15

Image: Evidence-Based Design Wheel (Geboy, L., 2007. Healthcare Design 7(2): 41-42)

Slide 16

How Strong is the Evidence? Examples of Environmental Properties that Affect Outcomes

• Single versus double rooms
• Noise
• Windows versus no windows

Slide 17

Single vs. Double Rooms: Safety

• Single rooms have lower infection rates than semi-private rooms or open bays (Van Enk and Nyirenda)
• Fall rate decreases in single rooms (Brandis)
  • Falls reduced 75% at Clarion Methodist Hospital by changing double rooms to single rooms
  • Wide bathroom doors prevent falls
• Room transfers are associated with increased medical errors
  • Due to communication discontinuities between staff

Slide 18

Single vs. Double Rooms: Nurses Prefer Single Occupancy Rooms

• Nurses favor single-occupancy rooms (Chaudhury, Mahmood, Valente, 2006)
  • Flexible family accommodation
  • Suitable for patient exams
  • Higher patient comfort level
  • Improved patient recovery rate
  • Lower rates of medication errors
  • Less probable diet mix-ups

Slide 19

Single vs. Double Rooms: Patient Satisfaction/Costs

• Roommate can be source of stress (Ulrich, 2004)
• Higher patient satisfaction (Press Ganey)
• Confidentiality / Privacy (Pease and Finlay, 2002)
  • Reduced embarrassment
  • Opportunity for family members to participate in care
  • Avoidance of upsetting other patients
• Incompatibility among roommates leads to costly room transfers (Pebble Project-Bronson Methodist)

Slide 20

Single vs. Double Rooms: Noise

• Noise negatively impacts outcomes
  • Widespread annoyance among patients and perceived stress in staff (Hilton, Bayo, Garcia and Garcia)
  • Sleep loss / sleep fragmentation (Yinnon, Hilton, Berg)
  • Increased blood pressure (Yinnon, Hilton)
• Noise level is a greater problem in double rooms
  • More frequent at higher levels
  • Noise results from roommate, family of roommate, staff attending roommate
  • Stressful for patients and caregivers

Slide 21

Florence Nightingale on Light, 1860

"Second only to fresh air. I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery. I mention from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall.

• Notes on Nursing.: What It Is and What It Is Not, 1860.

Slide 22

Windows Versus No Windows

• Absence of windows linked with high anxiety rates and depression (Keep et al., Parker and Hodge)
• Lack of windows may aggravate sensory deprivation (Ulrich)
• Employees with views of nature report: (Leather et al.)
  • Less stress
  • Better health status
  • Higher job satisfaction (less turnover)

Slide 23

Evidence-Based Design: Staff Involvement

• Clinical User Groups provide "Operational Flow"
  • Involved front-line staff
  • Involved physicians
• Clinical partnership with Global Operations Teams

Slide 24

Patient Room Configuration

Hill Rom
Room Builder Workshop

Slide 25

Hill Rom Room Builder Workshop

Image: 5 images of the workshops interior are show.

Slide 26

Private Medical/Surgical Patient Room

Images of the following 3 sections are show.

• STAFF ZONE
• PATIENT ZONE
• FAMILY ZONE

Slide 27

Critical Care Patient Room

Images of the following 3 sections are show.

• STAFF ZONE
• PATIENT ZONE
• FAMILY ZONE

Slide 28

The Journey: Beyond the Built Environment

• Evidence-Based Design: Focus on complexity of work environment, physical space, and technology
  • How do we enable the provider to spend more time at the bedside?

Slide 29

Leveraging Technology: Impacting the Built Environment

• University of Pittsburgh Medical Center Shadyside Smart RoomT technology
  • Patient involvement (patient education, discharge instructions)
  • Alerts (time for repositioning, patient on "falls precautions")
  • Simulation: experimentation before implementation

Slide 30

Evidence-Based Design: Sustainable Journey

• Environmental Mission Statement
  • Inova Health System is committed to establishing an environmental program that contributes to a safer and healthier environment for our patients, employees and community. We will work diligently to develop a comprehensive environmental program for this healthcare system which is world class with sustainable and measureable outcomes.
• Project is registered with United States Green Building Council
  • LEED certification at Silver level is anticipated

Slide 31

Sustainable (Green) Design Principles

• What is "Green" Design?
• Design and construction practices that significantly reduce or eliminate the negative impact of buildings on the environment and occupants in six broad areas:
  • Sustainable Sites
  • Water Efficiency
  • Energy and Atmosphere
  • Materials and Resources
  • Indoor Environmental Quality
  • Innovation in Design

Slide 32

The Journey: Current State

• Economy dictated new footprint
  • Project redesigned to reflect ability to secure bonds / loans
• Previous work to incorporate EBD has proved invaluable
• Construction start date is July 2010

Slide 33

Image: INOVA Fairfax Hospital - South Patient Tower

Slide 34

Image: Inova Fairfax Hospital - South Patient Tower/ Women's Hospital

Slide 35

Image: Inova Fairfax Hospital - South Patient Tower & Women's Hospital "Green" Concepts

Slide 36

The Journey: Lessons Learned

• Evidence-Based Design principles must be incorporated into the organization's mission, values, beliefs in order to gain traction
• User-input, while time consuming, ensures the organization has sought opinions of those who will provide healthcare.

Slide 37

Another Journey: Visit to China

• Lessons learned