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Inova Health System

Evidence-Based Design: Inova Fairfax Hospital’s Journey

September 16, 2009

Reuven Pasternak, MDChief Executive Officer

Inova Fairfax Hospital CampusExecutive Vice President for Academic Affairs

Inova Health SystemFalls Church, VA

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Evidence-Based Design: Inova Fairfax Hospital’s Journey

• Objectives

— At the conclusion of the presentation, the participant should be able to describe:

1. At least 3 ways Inova Fairfax Hospital is incorporating evidence-based design elements to enhance patient safety and quality of services delivered.

2. The impact of evidence-based design on clinicians.

3. The role of clinicians in planning the building to reflect evidence-based design.

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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

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Inova Fairfax Hospital: Unique Service for the Community

Named a HealthGrades America’s 50 Best Hospital™ 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

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• 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.

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The Need: Impetus to Begin a Journey

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The Need: Impetus to Begin a Journey

• Unclear wayfinding (locating services)

• Women’s services significantly outgrew the current facility capacity

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1,076 1,171 1,253 1,319 1,347 1,376

335360

377392 403 414247

301354

410 449 469

400

469

519549

582614

-

500

1,000

1,500

2,000

2,500

3,000

2005 2010 2015 2020 2025 2030

Po

pu

lati

on

in 0

00

s

PrinceWilliam/Manassas -up 214K

Loudoun - up 221K

Alexandria/Arlington -up 78K

Fairfax/Falls Church- up 300K

The Need: Population Growth

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The Need: Aging Population

237,334

153,920

239,009

182,637

0

50,000

100,000

150,000

200,000

250,000

300,000

0-17 18-44 45-64 65+

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The Need: Demand for Obstetrics

OB Deliveries at Inova Fairfax Hospital1986-2030 (projected)

7,899

11,74413,000

14,500

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

1986 2006 2020 2030

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What is Evidence-Based Design (EBD)?

Center for Health Design (CHD) defines EBD as:

“The deliberate attempt to base building decisionson 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)

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Inova Health System: Mission, Vision, Beliefs

M I S S I O NTo 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.

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

CONTINUOUS QUALITY IMPROVEMENTVISION ● BELIEFS

MISSION ● COMMITMENTSMISSION ● COMMITMENTS

QUALITY

SERVICE

COST

PEOPLE

GROWTH

COMMUNITY

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Evidence-Based Design Elements: Linkage to Pillars

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Inova Fairfax Hospital

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Evidence-Based Design: The Journey with Eyes Wide Open

• Effects of healthcare environmental design on medical outcomes

— What does the literature reveal?

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

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

• Single versus double rooms

• Noise

• Windows versus no windows

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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

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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

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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)

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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

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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.

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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)

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Evidence-Based Design: Staff Involvement

• Clinical User Groups provide “Operational Flow”

— Involved front-line staff

— Involved physicians

• Clinical partnership with Global Operations Teams

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Patient Room Configuration

Hill RomRoom Builder Workshop

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Hill Rom Room Builder Workshop

STAFF ZONE

PATIENT ZONE

FAMILY ZONE2626

Private Medical/Surgical Patient Room

STAFF ZONE

PATIENT ZONE

FAMILY ZONE2727

Critical Care Patient Room

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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?

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Leveraging Technology: Impacting the Built Environment

• University of Pittsburgh Medical Center Shadyside Smart Room™ technology

— Patient involvement (patient education, discharge instructions)

— Alerts (time for repositioning, patient on “falls precautions”)

— Simulation: experimentation before implementation

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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

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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

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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

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INOVA Fairfax Hospital - South Patient Tower

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Inova Fairfax Hospital - South Patient Tower/ Women’s Hospital

Inova Fairfax Hospital South Patient Tower and Women’s Hospital

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Inova Fairfax Hospital - South Patient Tower & Women’s Hospital

“Green” Concepts

Inova Fairfax Hospital South Patient Tower and Women’s Hospital

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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.

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Another Journey: Visit to China

• Lessons learned