HCD_2011_MD Anderson study

1. E74: Teaming Up
Does unit decentralization impact teamwork and
operational efficiencies?
Pamela Redden, MS, BSN,RN, EDAC, Director, Clinical Facilities Development
UT MD Anderson Cancer Center
Janet Sisolak, Project Director
UT MD Anderson Cancer Center
Debajyoti Pati, PHD, FIIA, LEED AP.
Executive Director, CADRE; Rockwell Endowment Professor, Texas Tech

2. Acknowledgments
 HKS Architects
- Study sponsor and institutional support
 Center for Advanced Design Research &
Evaluation (CADRE)
 Texas Tech University
- Institutional support

3. Learning Objectives
 Understand the impact of decentralization on
the way nurses spend their time (efficiency).
 Understand the impact of decentralization on
walking distance.
 Understand the potential influence of
decentralized operations on presenteeism and
acute stress of care providers.
 Understand the impact of decentralization on
care providers’ teamwork and collaboration.

4. Agenda
 Drivers of decentralization
 Key questions
 The evidentiary challenge
 The MD Anderson project
 Study data
 Key findings

5. INTRODUCTION

6.  Bed utilization:
• Male – Female
• Smoker – Non
Smoker
• Infection
 Build fewer beds
 Increase
flexibility
Driver of Decentralization: Single Room

7. Key Area of Change # 1
 Increase in floor
area per patient:
• Larger footprint
for the same
number of beds

8. Key Area of Change # 2
 Support space
optimization:
• Race track
configuration
• Decentralization

9. Hypothesized Impact Areas
 Patient focused
- More time with patient
 Improved efficiencies
- Reduced non-productive time
- Reduced walking distance
 Collaboration, teamwork and mentoring?
 Stress reduction?
- Chaos, noise
- Socialization
 Productivity improvement

10. Agenda
 Drivers of decentralization
 Key questions
 The evidentiary challenge
 The MD Anderson project
 Study data
 Key findings

11. Key Questions
 Does decentralization influence time spent
in walking, queues, and hunting and
gathering?
 Does it reduce non-productive tasks?

12. Key Questions
 Does decentralization influence staff
interaction and collaboration?

13. Agenda
 Drivers of decentralization
 Key questions
 The evidentiary challenge
 The MD Anderson project
 Study data
 Key findings

14. The AECOM Study
 Six units
 Three hospitals
 Measurements:
- Functional space use
- Patient visibility
- Noise level
- Nurse perception of
work environment
 Findings:
- Time spent on
telephone/ computer/
admin higher in
centralized
- Consultation/
interaction less
frequent on
decentralized
Centralized vs. Decentralized Nursing Stations: Effects on
Nurses’ Functional Use of Space and Work Environment
(Terri Zborowsky, et al.)

15. The Taiwan Study
 Two units
 Two hospitals
 Measured:
- Staff interaction
- Patient falls
 Findings:
- Less communication
in decentralized
model
- Less patient fall
events in
decentralized model
Impact of Architectural Design on Communication among
Hospital Staff. (Chai Hui Wang)

16. The WHR Study
 Four units
 One hospital
 Measured:
- Patient satisfaction
- Nurse satisfaction
- Communication
- Walking distance
- Medical outcomes
- Organizational outcomes
 Findings:
- Increase in patient
satisfaction
- No significant
differences in any
other parameters
The Effects of Nursing Unit Spatial Layout on Nursing
Team Communication Patterns, Quality of Care and
Patient Safety (Franklin Becker et al)

17. Agenda
 Drivers of decentralization
 Key questions
 The evidentiary challenge
 The MD Anderson project
 Study data
 Key findings

19.  Location - the heart of the Texas Medical Center, Houston, TX
M.D. Anderson Cancer Center Background

20. • Texas Medical Center (42
member institutions, 13
major hospitals with
66,000 employees)
• A healthcare component of
the University of Texas
• Founded in 1941, M. D.
Anderson has grown to
over 18,000 faculty and
staff.
• More than $2.2 billion
annual revenue
M.D. Anderson Cancer Center Background

21. • 1998 – 1999
20% growth in patients
• 1999 – 2008
80% growth in patients
75% increase in employee
115% increase in research
revenue
• 2012 Projections
50% growth in patients
from 2006
M.D. Anderson Cancer Center Growth

22. Then and Now

23. THE BEFORE CONTEXT

24. Typical Nursing Floor
(4) 13-bed Units
All Private Rooms
Central Nurse Station
Racetrack Design
Service & Public Elev.
Albert B. and Margaret M. Alkek Hospital

25. Central Nursing
Station
Documentation
Station
Albert B. and Margaret M. Alkek Hospital

26. Albert B. and Margaret M. Alkek Hospital
Typical Amenities include:
• Murphy bed for family members
• TV/ Lodgenet
• Storage for luggage, clothing

27. Unit Configuration
 Centralized work concept
 Open medication prep
areas
 Family waiting areas
small/lacking
 Wayfinding challenges

28. THE AFTER CONTEXT

29. Expansion Project – Initiated in 2005
 503,000 Square Feet
Added
 11 Additional Floors
- 8 Inpatient Units
- Pharmacy
- Facilities support
- Mechanical / Electrical
 Observation Deck
 Current Operating Beds =
702
 Future Operating Beds =
962

30. 1.Need to maximize
the number and
size of patient
rooms per floor
using current
industry and best
practice standards
2.Need to improve
wayfinding for
families and
visitors
3.Need to add
family spaces &
amenities on floor
2 2
11
3
NN
Design Challenges – Patient/Family

31. 1.Need to increase
access to nursing
stations
2.Need to improve
staff and patient
circulation
3.Need to improve
support and staff
areas
1 1
22
3 3
NN
Design Challenges – Staff

32. Key Goals and Objectives
The new Alkek patient units will be designed
reviewing current evidence-based concepts
in a manner that:
 Promotes patient and family centered care
 Maximizes efficiency of work effort for all
members of the care team
 Includes ergonomic considerations that
minimize the physical burden of patient care
delivery
 Promotes interdisciplinary collaboration

33. Key Goals and Objectives
Additionally, key design elements should be
considered in relation to these guiding
principles:
 Promote safety for patients
 Enhance support for patients and their families,
recognizing that the family plays an active role in
the healing process
 Meet/exceed the needs of the care givers -
integrate technology, maximize staff productivity,
increase time at the patient bedside, minimize
footsteps, enhance ergonomics

34. Design
 Design-Build project McCarthy/HKS
 Nursing Leadership Design Team 2006
 Surveys on design topics- staff, physicians, caregivers,
patients
 Focus Groups
- Medical Team Members
- Staff
- Patients & Family Members
 Bulletins & Postings
 SharePoint Site

35. Design Solutions - Patients/family
1.Increased footprint
to accommodate
more rooms per
floor
2.Improved
wayfinding on unit
3.More family
waiting
4.Added consult
room
1
11
1
33
22
44
NN

36. 1.Improved staff
circulation within
core
2.Decentralized
staff stations at
patient rooms
3.Decentralized
meds and
equipment
3.Created team
rooms
1 1
22
3
3
3
3 4
44
4
Design Solutions - Staff
N

37. Inpatient Floors 15–17:
Typical patient room
 Increased room size (ranges from 251 s.f.–298 s.f.)
 Outboard toilet improves visibility of patient
 ADA-sized toilet enhances accessibility
 Improved family space
 Easier access to patient
 Caregiver work area within patient room
 PPE alcove outside room

38. Inpatient Rooms
Room Zones
• Family Zone
- Sleep Sofa
- Additional Storage for Family
- Individual Television
• Patient Zone
- Flexible Acuity
- Desk Work Area
- Headwall Ergonomics
• Staff Zone
- Hand washing sink inside room
- Locked medication storage
- C5 mobile computer

39. Decentralized Nurse/Staff Stations
• Decentralized nurse/staff stations with
patient view window
• Improved view of patients for
assessment purposes
• Encourages staff time with
patients
• Decreases staff travel time
• Distributed supplies/linen
• Creates quieter environment
Storage rooms and alcoves
• Maintain hallways free of equipment
• Support service areas (Lab, Nutrition)
TEAM
MEDS
SUPPL
Y
Unit Staff Support Areas

40. Unit Staff Support Areas
Medication Rooms
• Locked medication rooms added to
each pod on the new units
• Addresses Joint Commission
standards for medication security
• Permits focused, uninterrupted
medication preparation by the
nursing staff
Team Station
• Fully outfitted admin area for Roving
Patient Service Coordinator/Staff
utilization
• Central Physiologic Monitoring

41. Team Room
Team Rooms
• Multi-purpose rooms located on each
pod to foster interdisciplinary
collaboration and teamwork
• MediaScape Smart Media
Collaboration Table from
Steelcase – data network
connections w/ ability to display
images from on-board desktop
computers or laptops.
• Web conferencing capable
• Educational Initiatives
• Glass walls of Team Rooms can
be reconfigured if future utilization
changes

42. STAFF AMENITIES – INPATIENT UNITS
• Staff Tranquility/Working Mother’s Room
• Locker Room ~ Staff Shower
• Staff Lounge
• Shared Multi-disciplinary Desks
• Conference Room
Staff Amenities

43. CLINICAL OPERATIONS

44. Unit Model
STAFFING
 Staffing typically 2-3 patients/RN
 Support staff: CNAs and PSCs
 Clinical Nurse Leader, AD, ANMs
PATIENTS
 Leukemia
 Lymphoma
 Stem Cell Transplant
 “Mixed” hematology

46. Goals of the QI Project
 Assist in adaptation to the new unit design
 Identify new processes for
Communication
Collaboration
Task completion
Larger unit footprint
 Seek opportunities
Education and training
Modify design elements

47. Study Protocol
 14 staff data points for day shift/14 data points
for night shift (per unit)
 RNs carried PDAs and completed
corresponding pedometer logs
 PDA vibrates 30 times/12 hours, tasks and
location entered
 Filled out surveys

48. Study Protocol

49. Pre Occupancy Data Collection
“Pre” Data Collection
 January 18 – 31, 2011
G11 (Stem Cell Transplant) Alkek
Hospital
P6 (Hematology) Lutheran Pavilion
 February 1 – 7, 2011
G9 East (Lymphoma Service) Alkek
Hospital
 Written Surveys for 2 weeks – January 15
– 31.

50. Activation and Occupancy
 “Bed shortage”/high census impacts
 Phased occupancy
November 8, 2010 G16 G10W 26 beds to G16 48
beds
March 7, 2011 G17E: 12 beds open
March 14, 2011 G17W: 12 beds open
May 16, 2011 G15: G9E to G15

51. Post Occupancy Data Collection
“Post” Data Collection
 September 8 – 22, 2011
G11 & G17 SW
 September 26 – October 9, 2011
G15 & G17 SE
 Written Surveys for 2 weeks – September 1 – 15

52. Activation and Occupancy
Activation
Management Team
Operations
Planning
Move
Management
Communications Training
Facility
Readiness
•Programs/Service
s
•Policies
•Systems/Procedu
res
•HR Functions
•Process Design
•Operating Budget
•Scheduling/
Sequencing
•Packing/
Labeling
•Department
Relocation
Management
•On-Going Staff/
Employee
Communication
•Opening Events
•Patient
Communication
•General Facility
Communications
•Operation
Simulations
•Training &
Orientation
•Master Training
Schedule
•Facility
Planning/
Development/
Construction
•Furniture/
Equipment/
Signage
•Facility
Completion/
Startup

53. Activation and Occupancy

54. Activation and Occupancy
Training and Education
Orientation methods
First new floor challenges
New workflow
New team members

55. Educational Resources

56. Educational Resources
• Short computer-based training modules developed to assist with
training utilizing Camtasia PowerPoint Voice Over Program
• Vocera
• Bedside supply cabinets
• Biohazard and linen pass-thru cabinets
• Team Rooms
• Multidisciplinary workrooms
• Medical team rounds
• Unit orientation
• Medication room

57. Operational Factors
 Children’s Cancer Hospital Expansion needed temporary inpatient
unit.
 Issues with showers and smoke dampers requiring moves of patients
floor to floor before full occupancy.
 Increase in monitored beds-
decrease in ICU census

58. Operational Factors
 Operating a 24 bed “unit” vs. 13 bed “pod”
 Physician and medical team “centralized practice” concept
 Staff rotations
 Unit culture/staff roles

59. Post Occupancy Reviews
 Staff feedback sessions August, 2011
 Themes:
o “Unit Spread Out”, harder to find people/staff
o Patient assignments now need to consider
geography
o “View windows” yes or no?
o Pod vs. Unit function
o Like new medication room/system
o Team room use by medical staff
o Push button locks vs. badge

60. Agenda
 Drivers of decentralization
 Key questions
 The evidentiary challenge
 The MD Anderson project
 Study data
 Key findings

61. DATA TYPES

62. Data Types
 Nursing time:
- Rapid Modeling PDA
 Walking distance:
- Pedometer
 Acute stress:
- Current Mood State Questionnaire
 Presenteeism:
- Koopman Stanford Presenteeism
Scale (Modified)
 Staff interaction and collaboration

63. PDA TCAB Data Classification
 Task Type
- Value adding
- Non value adding
- Necessary
 Task Category
- Direct care
- Indirect care
- Administrative
- Personal
- Waste
- Documentation
- Other
 Task Location
- Nurse station
- Patient room
- On the unit
- Patient medication
- Supply storage
- Conference room
- Off unit
- Documentation server
- Other

64. Data Collection
J F M A M J J A S O
BEFORE DATA AFTER DATA
UNIT A
UNIT B
UNIT C
UNIT A
UNIT A NEW
UNIT B NEW
UNIT C NEW
2011

65. Agenda
 Drivers of decentralization
 Key questions
 The evidentiary challenge
 The MD Anderson project
 Study data
 Key findings

66. Identifying Patterns of Change
Multiple unit
comparison benefit

67. Identifying Patterns of Change
Care processes, physical environment, culture
and policies interact
PATIENT
PATIENT OUTCOMES
PHYSICAL
ENVIRONMENT
CAREGIVER CARE PROCESSES
GROUP PHENOMENA:
CULTURE RELATIONSHIPS
POLICIES

68. Identifying Patterns of Change
 Performances change after intervention
 The key question is consistency

69. Task Category: Documentation
15
17
19
21
23
25
27
29
31
33
Unit A Unit B Unit C
Before
After

70. Task Location: Nurse Station
25
27
29
31
33
35
37
39
41
43
45
Unit A Unit B Unit C
Before
After

71. Task Location: On The Unit
0
2
4
6
8
10
12
14
16
Unit A Unit B Unit C
Before
After

72. Task Location: Medication
0
2
4
6
8
10
12
14
Unit A Unit B Unit C
Before
After

73. Task Location: Supply Storage
0
0.5
1
1.5
2
2.5
Unit A Unit B Unit C
Before
After

74. Walking Distance
1.5
2
2.5
3
3.5
4
Unit A Unit B Unit C
Before
After

75. Documentation
15
17
19
21
23
25
27
29
31
33
Before After After New

76. Nurse Station
30
31
32
33
34
35
36
37
38
39
Before After After New

77. On The Unit
5
5.5
6
6.5
7
7.5
Before After After New

78. Medication
0
2
4
6
8
10
12
14
Before After After New

79. Supplies
0
0.5
1
1.5
2
2.5
Before After After New

80. Walking Distance
1.5
2
2.5
3
3.5
4
Before After After New

81. IMPLICATIONS

82. Implications
 Documentation
increase
 Is it because
documentation
stations/servers
are more
accessible in a
decentralized
configuration?

83. Implications
 Nurse station
use decrease
 Is it because the
need for
documenting
inside a nurse
station is
reduced?

84. Implications
 On unit location
increase
 Associated with
nurse station use
decrease?
 Does this
represent an
increase in inter-
personnel
collaboration/
interaction.

85. Implications
 Medication room
location
increase
 Because of easier
access?

86.  Supply storage
location
decrease
 Are supplies
being delivered
inside patient
rooms?

87. Implications
 Walking
distance
increase?
 Counter intuitive
 Does this
represent an
increase in inter-
personnel
collaboration/
interaction.

88. SUMMARY

89. Lessons Learned
Operational planning vs reality
- Paper intensive processes
- Added Telemetry reduced ICU census
- Geographic patient assignments new reality
- Chemo and blood products require two-nurse checks
- Feelings of isolation
- Missed ‘teachable moments’ for new staff
- Infection control discussions
- Medications “at the bedside” on the wish list
- Cannot get all supplies to the bedside