- 1 PERSONAL BACKGROUND
- 2 DIARY
- 2.1 Class 1 - Tue, Aug.21st
- 2.2 Class 2 - Thu, Aug.24th
- 2.3 Class 3 - Tue, Aug.28th
- 2.4 Class 4 - Thu Aug.30th
- 2.5 Class 5 - Tue Sep 3rd
- 2.6 Class 6 - Thu Sep 6th
- 2.7 Class 7 - Tue Sep. 11th
- 2.8 Class 8 - Thu Sep 13th
- 2.9 Class 9- Tue Sep. 18th
- 2.10 Class 10- Thu Sep. 20th
- 2.11 Class 11- Tue Sep. 25th
- 2.12 Class 12 - Thu Sep.27th
- 3 READING QUOTES
- 4 IRB
I am a PhD student in Department of architecture at Georgia Institute of Technology. I had professional Architectural degree from China. And I got my master degree in architecture from National University of Singapore. I was invovled both in designing practice and research in China and Singapore for several years. My current interest is in cognition, environment & behavior. I am especially interested in the relationship between human interaction and space. email: firstname.lastname@example.org
BTW, I work as teach assistant for this class. So I may take some pictures during class to document the class process. Hope you guys are not disturbed by my "weird" behavior. Anyway, I am very excited to working together with you guys.
Class 1 - Tue, Aug.21st
Possible Directions in Pediatric Hospital Research
1) What's the difference between children hospital and other acute care hospital?
2) Facing the shfit from emergency room to primary care, how to make it efficient & effective during the transition to emergency room?
3) How to deal with safety issue? e.g IFRD...
4) What makes a children-friendly environment?
5) What can we do to design a place for patient & family members to spend their time?
6) How to create a healing & calming environment?
7) Revolutionary idea about "waiting area". Is it possible to be a physical therapy area as well? What kind of design elements can create divergence of the patients and family mambers' stress?
8) What does patient-centered care mean in children hospital?
9) How to combine virtual and physical space?
10) How to create an environment that can accomodate changes?
Class 2 - Thu, Aug.24th
Evidence-based Design---Children Hospital in Hughes Spalding
The design of Children Hospital in Hughes Spalding is an exciting practice in evidence-based design.
- Consideration for staff
- Efficiency of nurses is highly related to location of nurse station and substation.
- Poor handwriting of doctors may cause serious medical errors.
- Windows in staff lounge will increase staff retention.
- Internet connection everywhere and COM (computer on the wheel).
- The interface and way to use new technology. It is a big challenge not only for new nurses, but also for old physicians and nurses.
- Consideration for patients
- Light, music and color has active impact on healing process.
- Transparency of information. How to make the process clear to the parents and hence reduce their stress? Users measure the quality of care not just by the technique qualification, but also by their own experiences.
- Consideration for care process
- Hughes Spalding is shifting to more primary care oriented. It is an obvious trend in other hospitals in USA now. The length of stay is shortened and the care is focusing on primary care. It tends to be more accessible by users.
- Most of the doctors are not employed by the hospital. It is another trend of healthcare. There is even an increase some physician office run by indepedent physicians.
- Some term explanations
Primary care, special care, outpatient treatment and inpatient treatment
Primary care refers to the regular checkup;
Special care refers to the care other than regular examination, but no need to stay in hospital;
Outpatient treatment refers to the treatment that the stay in hospital no longer than 24 hrs;
Inpatient treatment refers to the treatment that the stay in hospital more than 24 hrs. General inpatient refers to diagnostic.
Class 3 - Tue, Aug.28th
Evidence-based Design (EBD)- Lecture by Dr. Craig Zimring
- What's EBD?
Evidence-based medicine - Evidence-based practice -Evidence-based Design
Dr. Zimring impressed us with a lot of stunning numbers and data.
- 3-17% of the patients were injured.
- 10% of all patient got wrong medication.
- For every 1K patient days, 3.5 patients fall, and it costs $10K for the unlitigated cases. (Now $20K!) The money is absorbed by hospital and not covered by Medicare/Medicaid.
- Planned hospital in next 2-5 years ranked 2nd in the whole national investment.
- More evidence than expected: 800+ rigorous studies.
- Communities for EBD
- 39 active centers
- MHS (Military Healthcare System)
- Kaiser Permanente
- Emory Hospital and Clinic
- LSU $800M (Katrina reconstruction)
- Goals (To improve care quality & safety)---EBD Features---Outcomes
|Enough light during nurses work (esp. complex task)||Reduce pharmacy & medical errors|
|Location of sink||Reduce contamination of MRSA|
|Acoustic level||Related to get speech intelligibility, worsen patient & staff outcome|
|Family zone, patient zone & care zone||Improve patient, family and staff satisfaction (Emory)|
|Waiting room has variable seat arrangment||Improve family satisfaction|
|Support care for whole person (control of natural light,nature and positive distraction||Reduce length of stay and medicine use, fewer stress|
|Postive environment for staff||Reduce staff injuries and trun over rate|
|Maximum standardization, Acuity adaptable room||Flexibility, encourage multidisplinary use|
- Business case "Fable" hospital
One year cost savings $7.8M -
One year revenue increase $3.7M -
Cose Increase 5% $12M +
The increase investment of EBD can be returned in one year, while achieving a much higher quality of care.
- Questions in mind:
1) How to systematically collect "evidence" and compile them?
2) How to calculate the increase of investment for EBD?
3) Most of the evidence are from inpatient care, how to apply them to outpatient care? What are the common points and what are the differences?
Class 4 - Thu Aug.30th
Visit the Hughes Spalding Children Hospital
- Entry lobby is small and doesn’t have enough information to help the patients and family members to navigate themselves. The door in the employee lobby can be exited but cannot be re-entered without authorized card access. But there is no obvious sign to tell patients and visitors not to exit if they want to re-enter from this door. Being locked outside will definitely increase their stress.
- Overwhelming colors and lack of theme. It made the space appear more cramped and busy.
- Poor design of waiting room. There are some toys and small chairs in the waiting room. But chairs are arranged along lines like a classroom. The toys are ages old and cannot attract children at all. There are no considerations for parents at all. How can they remain the connection to the outside and keep their daily life as normal as possible?
- Scary tunnel to transport patients to Grady Hospital. There are no art works in the tunnel wall, no natural light and no music distraction in the one mile long tunnel. Even for adults, it is an unpleasing journey, not to mention sick kids.
- Privacy is a big problem. The ED room is a multi-beds room separated by curtains. How can the patient’s information not being overheard by his/her neighbor? And there are not enough spaces for different kinds of communication, such as the communication of family members and nurses, nurses and other medical staffs etc.
- Lobby is important first image to the patients and their family members. There should be enough information provided for patients and their parents. An interactive touch-screen computer can help the visitors get the general idea of the hospital and may be able to navigate in the space without uncertainty and stress.
- An efficient color code can help to relieve the stress and aid wayfinding.
- Provide effective distraction (personalize art decorations, music) in waiting area for kids. Introduce the efficient surveillance device that can get kids’ condition easily and keep them in contact with their parents. The design of waiting area should also consider the parents’ needs, make their life as normal as possible by providing business corner. Design of waiting area should also consider the communication for nurses and family members and other social workers.
- Transport equipment instead of patients. Mobilize the medical devices. Furthermore, there should be art work displayed and music played in the tunnel to distract the patients.
- Design a nursing floor which has better visibility and can create more opportunities of informal communication between nurses. At the same time, design different places that can accommodate different types of communication and meet different needs of privacy.
Class 5 - Tue Sep 3rd
Lecture by Gerri lamb--Q: What’s the difference between family-centered and not family centered healthcare space?
- Design model: Think interaction
Culture change-Work process-Physical environment-Technology
- Pivot the room: Who are the stakeholders?
- medical care workers
- kids and their patients
- facility management
- information systems
- Low budget, try to be as creative as possible.
- Equitable - SES(social Economic Statistic)
- What do children and their families want from health care?
- stay healthy
- get better quickly when ill
- live a good life with Chronic illness (high quality of life)
- Die comfortably and supported
What is Patient-centered care? - Choice: patient’s preference, hear and communicate to the patient, make the healthcare system works for the individual. Give alternatives and explanations to patients. - Listen to family members and ask them about their needs. Patient and Family centered care: To customize care to the specific needs and circumstance of each individual, to modify the care to respond to the person, not the person to the care.
- CAHPS survey on parents’ experiences
- Communication and interaction
- How well are we doing in patient-centered care?
- Staff shortage and the current situation in healthcare system
- An interesting finding: 20 seconds to talk with physicians without being interrupted.
- Good intentions--------poor system to support good intentions
- How can we create better system to support people to provide better care?
- What will an experienced nurse find in the first moment when they see the patient?
- Look at everything, skilled clinics can do this very quickly. Get a lot of information in the first minute you walk into the room. Make assessment, "diagnose"
- PDCA: Assess (Plan) ---- Intervene (Do) ---- Evaluate (Check& act)
- Self care--- at school, home….
- Diet, Exercise, Sleep, Treatments, Medication, Symptom monitoring, Seek care in a timely way
- Teach the parents to help to monitor their children’s disease. How to watch the crisis, how to deal the crisis?
- What should a child and family-centered environment look like? How does it look, feel act differently than one is provider-centered environment? For example, how is the parents-waiting room look like?
- Resources: Mediline, scienceweb, www.ihi.org
Class 6 - Thu Sep 6th
1. How do we get information from clients?
2. What are the things that go wrong?
3. How can we help them to make the right decision?
1. How do we get information from clients?
- Tools to get information from clients:
- Observations (culture and what are the things that are doing right/wrong)
- Notice those “walk around”, the inappropriate way to do things different from the protocol or the right way, because that reflect the real users’ needs.
- Go with a list of questions at hand. Go through as a patient’s experience. Observe shifts time in ER.
- Exmaple: No rooms for patients. Surgical capacity is a big problem for patients. Get to realize the real problem. It is not just enlarge the space without thinking the real function for the space.
2. What are the things that go wrong?
- Risk-adverse culture
- Conflicting agendas
- Lengthy process/regulatory constraints
3. How can we help them to make the right decision?
- How to get the right decisions:
Synergy of different people: experts, line staff, outsiders
- Florida Hospital
- Adopt-A-Room, Minneapolis, MN (renovation project)
1. wider beds to parents to lie down
2. homelike shower
3. Recess room with visual & acoustical privacy (LCD distraction)
4. small and isolated office area
5. family zone- healthcare provider zone-patient zone-family zone
6. Virtual sky-light
- Joan Glancy Replacement Hospital Duluth, GA
- third party MOB
- OP and MOB under separate construction to save cost
- OP has beds
- Mercy Health System of NW Arkansas Rogers, AR
- Replace the old hospital
- integrated delivery process
- complete redefinition of operations as part of design process
- Halifax medical center Daytona, FL
- How can we make the construction and work more efficiently?
- Single-hand PR
- In a racetrack plan, how to eliminate the core and make it as transparent as possible?
- Resolve the conflict between distributed nurse station, getting nurses closer to patients or keep nurses together since they are socialized, and need to help each other out.
- Quiet area for doctors and other staff
- “touch down’ station, serve 6 rooms (reduce walking distance) Nurses try to get everything from the meds room and resource room to the cart during the beginning of the shift.
- Design is adaptable to any patient type or acuity level (universal room) normal-fast-track -critical-trauma
- Improved visibility
- Resource area for family (family collaboration)
- Modular approach v.s. PODs (half self-enclosed PR, cannot see the other PR, and have to exit from the entry way) Modular allow visibility from other rooms, and can open up to larger rooms.
- 8 modules, 36 beds (2 subparts composed of 18 beds). In 2 years, it will start operation.
- Ronald Reagan UCLA
- University of Miami Miller School of medicine Miami, FL
- Single-handed rooms with a rail from the bed to the toilet
- Mock up to evaluate changes
- Craig: The medicare and medicad are not paying the medical errors any more. It is an opportunity for EBS. How to improve physical environment and reduce medical error?
What are the differences of kids? What are the differences of ambulatory care? Answer: 1. More family members; 2. Separate exam room and the room the kids stay in;
- Home like PR, Hotel-like hospital; hospitality in hospital, is that a misdirection
- Waiting room design
Kaiser Permanente, part modular design, part flexible design;
Self reflection: The designers play an important role to implement the ideas and questions of the users to the real physical environmnet. But some of the designs seem to still base on the rule-of-thumb. A scientific POE and approval of the evidence is in great need. They will help to advance the physical care environment and care culture in turn.
Class 7 - Tue Sep. 11th
Ellen Do’s Lecture 1: Healthcare IT Challenges and Opportunities
1) Electronic Medical Record (How to make sure all the information is correctly input?)
2) How to balance Grady system and CHOA Management together?
Wireless Network, Client application, parent access
Medical Home Idea: every care givers share the records and all records can be put together and follow the patient. Make them work together and collaborate to help the patients, even with electronic system assistance.
REAL: Regional electronic application library??
Records don’t follow the patient or use different format of record will cause medical errors. 3) Information visualization (how to represent the data to different people? like parents and professionals)
4) COW- computer on Wheels (how to deal with privacy issue and security issue)
5) Interactive Donor Walls
6) Patient distraction (X Box, Virtual play ground such as i-dog, virtual football,Education, Entertainment)
7) Care pages like personal blog to share the experience to cure the disease
8) How to analysis, visualization the clinical data?
9) Back-up data and up-to-date data record
10) Tele-medicine: the mobile medicine to scan patient’s information (e.g. barcode on bracelet), record the symptom, scan the medicine.
Ellen Do’s Lecture 2: Design, computing and physical environment
From hand to body to large environment size
- Digital finger touch
- Espresso blocks (define your own façade)
- Intelligent kitchen
- Music under pressure
- Interactive window seat
- Interactive environment
- Alphabet Paint Space (create person interaction)
- Movement and nature (step on tiles to show the growth of trees)
- How to make the ambient environment intelligent?
Reduce the noise of the ICU by showing the nurse the information through the change of environment (setting up the spin-wheel for each room).
- How to get the caregivers to wash their hands?
Try to take care of the culture and the physical environment?
- What prevents the hospital to use the Patient Distraction Technology?
How to get transparency in care process? How to help the kids understand what will happen next, what will you do in tomorrow’s operation, examination?
- Virtual nurse guide
Write the nurse’s information on the whiteboard, and encourage them to talk to the patients.
Class 8 - Thu Sep 13th
DJ Feather, Lecture Children’s healthcare of Atlanta ---- Clinical Involvement in Hospital Design"
- Facilities are always on the other side of organization.
Innovations have to base on the budget.
- Hospitals have strong culture---What is the culture of children care at Egleston?
Clinical people should be heavily involved in the facility design, because they are the persons who are going to use it afterwards.
- $360 million dollar expansion;
-bed increase from 430-505
- 640,000 sf new construction and 237,000 sf renovation
- Relationship between key principles and key benefits, can the key principles be extended through the end of the project?
- Master facilities plan team structure:
- Interior Design
- Information system/Technology
- Industrial Hygiene
2. Campus based:
- Construction director
- Operational Project director
- Write down a list of program about what are needed spaces in the very beginning and get it back to architects. Then architects check with the budget.
- How will the innovation happen during the programming phase?
Decide the scope before the decision making, before the budget definition and function programming.
- Workplace redesign:
Workplace redesign initiative identified as key tactic in recruitment/retention plan by CNE. Involve nurses in the process, staff level participation; Team composition: each team composed of 2 staff from support area and 5 or 6 from patient care area.
- Process issues: look at all different processes
Work process: Function over Form
• Care teams identified key processes for:
- clinical care
- Family support
- Business operations
- Staff and management
- Focus on the basic task of clinician.
The patient flow is also considered in the function programming stage.
- Best practice integration: facility tours
Criteria for site visit selection: focus on the process instead of image
- Final deliverable: Design Specification: come out 122 design elements
Example: elements for Critical care
- overall unit design (medication room)
- Boom headwall systems
- Conveyance system (How to transport the facility from outside the hospital to the hospital)
- Exterior windows
- Defined zones ( patient zone, care zone and family zone)
Fullfill the design elements requirements according to its priority.
- Room Mock-up (Full size mock-up & Bedside test)
- Review of furniture, functional layout and architectural detail,
- General inpatient room
- CIRU inpatient room
Class 9- Tue Sep. 18th
David's lecture: staff process
- The IOM’s goals:
- Patient centered
It is possible to design a hospital more effective and more efficient without increasing the cost (economical).
- Run hospital and design hospital, two different systems, how to balance them?
- Modular construction in temporary hospital design, can that used in “flexible waiting room” design?
- Work between balance on patient and provider. Patient-centered doesn’t mean to ignore the nurses and staffs’ needs.
- Try to understand the trade-off in the innovations, e.g. HIPPA. The privacy of patient is important while the efficiency of transferring the patient’s data is important as well. How to balance these two needs and where is the trade-off part?
- Engineer’s approach to challenges:
- Systems way of thinking
- Quantitative: measurements, structure(organizational structure)
- Practical (whether it is workable? Project management, time management etc.)
- Leadership (Natural leadership; Recognize the value of people in your group)
- Brainstorming (Good & bad ways of brainstorming, the direction of the discussion, get around the group, each one speak out the idea without judgment)
- Structured Decisions
- Divide & conquer (make on-time decision when needed)
- Deference, honoring the decision
- Action (second week of Oct.)
- The Challenges before us
- Pediatric is different from adult care
- Healthcare management is more complex than average manufacturing industry
- The Center (it is not just a hospital. Health center is more complicated than hospital
- The culture context
- Balancing the priorities (budget limitation, flexible and changing situations)
- Innovation (financial problems, too many players on the round table, proof of evidences)
- Q & A
- Gerri: The new policy mentioned if there is any preventable approach to reduce infection hasn’t been done by hospital, hospital will lose money for it.
- Gerri & Craig: How to balance the needs of now and the needs of future?
- Not all are 4 years old (0-18 years), design for all different age groups;
- They are not alone- mothers and grand-mothers, how many seats in the waiting room?
- Development (Body conditions are changing and more complex, social needs-emotional problems)
2) Fun and Important of course!!
- Statcom.com- virtual patient journey, www.statcom.com/flash/loader.html
Screen in waiting room to show the patients’ family members about patients’ conditions
Very interesting flash, which shows the sequence of patient’s experience from enter the ED to Cath lab to Med/Surg. to the patient room to discharge. Some new technologies are included in the virtual journey, such as the electronically check-in and coordination system.
- The health center has a wide range of services.
Central place to do the triage before the diagnose result coming out.
Cultural social issues, relationship with Grady
What is the technology/system change that can bring the change to the field?
- Self Reflection
David has shown us a very interesting view as an engineer, which is very different from architects. I am keen to see how different disciplines will collaborate and how will the sparkle work in our project. At the same time, how to get the balance and define the trade-off is also an interesting question to answer.
Class 10- Thu Sep. 20th
Group idea presentation
Presentations are focused on serveral issues:
For patients and family members, the wayfinding issue seems not only related the efficiency, but also related to their stress level.
Different groups proposed different appraoches to this issue:
- Interactive 3D model
- Mobile phone (with blue tooth) as information kiosk and can download map
- Virtual reality wayfinging training and testing
- RFID record of handwashing
- Red infare
- Odor symbol
3) Positive distraction
- Digital paint wall
- Headphone, head-video
- Tutor patients
4) Waiting room design
- Design for different user group
- Information corner
- Business corner
- Flexible furniture design
- I-dog provide audio tour guide, audio medical-page to share information with other kids,help kids connected with their parents and caregivers
5) Care model and care process
- Recurring patients with nurse preferance record
- Remote control on chronic disease
- Transpency of care process (webcam etc.)
Most of the teams proposed solutions instead of PROBLEMS.
And at the same time, we should keep BUDGET-TECHNOLOGY-TIME in mind.
Target the problem on Hughes Spalding!
Class 11- Tue Sep. 25th
Group idea presentation-continue last week
Three other groups in the class presented the problems in Hughes Spalding Children Hospital and gave out some solutions accordingly.
- Handhold GPS
- RFID tracking
- Physical environment intuitively helps wayfinding
2) Optimize patient flow
- Map patient flow in physical plan
3) Positive distraction
- Children COW
4) Efficiency and felxibility
- Universal room and modular design
- Video-streaming of patient's information or conversation with doctor and send to patient's cell phone. It helps them keep the reference of diagnosis and treatment information.
Our "transformers" group further sharpened the problem after the presentation. We identify three important problems.
1) Ignorance of physical and psychological needs of different user group.
- Chairs and seat arrangements are impersonal
- Lack of information for different group (waiting room is not just for waiting...)
- Lack of space for communication and interaction
2) Lack of self-monitor for chronic disease increase unnecessary hospital visit
3) Lack of transparency and sense of control for both patients and families
Class 12 - Thu Sep.27th
- Sound control- Staff stress
- Private rooms
- Communication privacy
- Natural view- stress-LOS
- HEPA filtering-infection
- Care coordination-LOS-satisfaction
- Tele-access to care
- Acoustic-stress-return hospital
- Culture (Collaboration)-outcomes
- Patient-centered care
- Specialized care
- Primary care
- Emergency care
- Warm atmosphere
- Increase volume
- Address social-economic
- Teaching Residents
- Transfer knowledge of care between caregivers
- Improve the return care, long term inpatient care
- happens in different degree of rigor;
- happens outside the domains;
- Sources of best practices:
Center of Healthcare Design
AIA annual report
Best ICU design
- How to come out the principles?
Sources: Evidence, Community goals, Benchmarking best practice
PRINCIPLE --- GOALS --- PROBLEMS --- STRATEGY CONTEXT CONTEXT CONTEXT
Top ten design components in creating a world class children's hospital
1) All private rooms, the larger the better, of between 275 and 375 square feet, including full path, parent sleeping area, large sceen LCD/DVD, internet access, closet, desk, refrigerator, with windows from the corridor and attractive external views.
2) Cluster rooms in neighbourhoods of 8-10-12 based o nursing staffing ratios with central areas for staff and parents and ideally visibility into all rooms.
3) Include decentralized nursing/staff charting areas between the rooms with observation and privacy options.
4) Provide space and amenities that recognize the importance of the staff, which will enhance retention and recruitment, for example, attractive lounges and locker space.
5) Provide all necessary amenities that encourage parents to not just spend the night, but to participate in the care of their children.
6) Design a facility that appeals not just to kids, but to all generations, including staff, siblings, parents, grandparents and the cimmunity at large.
7) Recognize the importance of art (including performance art) and create a permanent collection that comtinues to grow and provide opportunities for art as a therpeutic agent, for example, an art studio or artist-in residence program.
8) Create "wow" factors, theming opportunities and educational exhibits that tie to and engage the local community and the schools and provide inspiration.
9) Recognize the importance of the lobby as the second most important impression after the exterior and a "town center" full of diversion.
10) The exterior should not look like a hospital or institution.
--- Fiona de Vos, "The top ten list", in Robyn Beaver (ed.), Designing the World's Best Children's Hospitals: The Future of Healing Environments,Mulgrave, Vic., Australia: Images, P.149.