In Efficient Healthcare: Overcoming Broken Paradigms, nationally recognized healthcare architect, David Chambers, AIA, shows that when hospitals are designed properly they can transform the way people work together, increasing efficiency, decreasing costs, improving quality and enhancing patient safety. He argues that architecture and design encourage behaviors that contribute to our collective capacity to accomplish great things, and applies that principle to healthcare.
Chambers' publication was conceived after his own near-fatal heart attack requiring CPR and a subsequent stay at a hospital, where he had plenty of time to consider the functional and economic challenges facing hospitals—and their possible solutions.
Chambers evaluates the effect of increasing specialization in medicine and the fragmented architecture of individual clinical spaces it has driven—resulting in added costs in terms of time, money and diminished quality. With patients increasingly being cared for by multiple specialists, these regular hand-offs of patients from one specialty to another may lead to inefficiency and increased medical errors. Also considered is that the dispersal of departments throughout a large hospital or clinic system may put patients at greater risk for infections because of their frequent movement within the health system.
Recounting the history of healthcare architecture, Chambers describes the patient-centered care movement initiated in the 1980s. With this trend, he believes the proverbial pendulum had swung too far, resulting in significant added cost and inefficiencies in staff utilization to bring all services to each individual patient.
Modern healthcare architecture seeks to find the compromise between the archaic department structures, which he calls silos, and the high-cost healthcare systems of thirty years ago. Chambers et al strive to design and build healthcare buildings in a cost-conscious way to break down departmental barriers where integrating providers maximizes opportunities for collaboration. Spaces should be designed to enable every member of the staff, from a maintenance worker to administrator to nurse and surgeon, to coordinate for the benefit of the patient.
Chambers analyzes the organization of a typical acute secondary care facility, demonstrating that patient flow is random and poorly coordinated. Because of multiple starts and stops and various queues, as well as the departmentalization, there are few opportunities to leverage staff skills. In addition, space is not well utilized, and information flow lags to the point that it does not inform patient care. This type of organization results in stalled patient service.
Instead, he provides the example of a clinic designed for high quality and efficient pre-operative medical clearance for surgery patients and demonstrates how cross-trained staff can deliver services in a supervised area of the hospital so that there is little wasted motion for patients and staff and minimal redundancy. He elaborates on the effective pre-operative clinic design, which emphasizes optimal patient flow and organization with a single queue and check-in, with just two steps preceding the actual services provided, all with more predictability. The simplified patient access makes better use of space and intake locations more universal, and allows for more flexible response by staff to different service demands. Elimination of hand-offs would reduce staffing requirements and improve overall care. He shows both patient and staff satisfaction benefits for designing the clinical workspace to support this program.
While advocating for health system work-flow processes that reduce costs, improve efficiency and add real value for patients, Chambers acknowledges that only when the entire system is committed to implementation of these principles, from the top down and the bottom up, can they be successful. Work flow cannot be optimized when facilities conform to departmental models of care, for example, when surgery is developed separately from needed imaging, or diagnostic cardiology is positioned floors apart from interventional cardiology. He criticizes the establishment of self-contained service units, with their own cultures, optimizing flow within their own micro-systems, but designed without consideration of related essential services, and emphasizes the value of optimizing system-wide flow.
One example is the typical configuration of the intra-operative magnetic resonance imaging (MRI), entirely enclosed within the operating room area and not readily accessible for outpatient use. A more optimally situated machine may be positioned with access through the operating room for surgical patients and with a separate entrance and preparation room to perform MRIs for children and adults under anesthesia. This dual-use technology, by virtue of its location within the hospital, would promote greater utilization of a high-cost technology, while improving safety and efficiency.
Another example of practical design steps that can be taken to improve safety and efficiency is locating computed tomography (CT) scanners in close proximity to the neurosurgical intensive care unit, particularly for trauma centers. When evaluating the time in motion and resources needed to move a potentially unstable, intubated patient from the neurosurgical ICU through corridors and down elevators, one must also take into account the staff time involved and the alternative use of that time for patient care rather than transportation.
An outdated design then becomes both an inefficiency and potentially a patient-safety issue.
Chambers' case for changing a broken paradigm comes at an opportune time for all medical disciplines, whose stake in the development of less costly, more efficient and better care is paramount. Rather than accepting the time-honored Frank Lloyd Wright adage “form follows function” today's healthcare architects believe that “form facilitates function.” David Chambers' provocative publication on efficient healthcare through better design could go a long way in driving needed transformations in healthcare delivery.
EDIE E. ZUSMAN
1. Chambers A. Efficient Healthcare: Overcoming Broken Paradigms, A Manifesto. Rice University Building Institute, 2009.
2. Macheske P, Matejowsky L. Architecture for Image-Guided Neurosurgery. Healthcare Design. 2010;10(1):38–42.
3. Pratt A. Condell Medical Center Libertyville, IL. Healthcare Design. 2004,4(3):118–120.