AIA guidelines for hospital planning.

AIA guidelines for hospital planning:

http://www.scribd.com/doc/61018483

Staff who resist quality improvement efforts

-by Donald Tex Bryant


Perhaps you are just beginning a quality improvement program or project.  Perhaps you have several project improvement projects successfully completed at your healthcare site.
No matter what your level of experience, you have encountered staff who are roadblocks to your efforts.  What are you to do?  Ignoring them or doing nothing will imperil your quality efforts eventually.  Let me share some ideas on what to do based upon my own experience and on advice from experts.

Before I share some strategies I will share an example based upon my own experiences.  A primary care group with six physicians specializing in family practice and internal medicine has been focusing on process improvement and patient-centered care for six months.  They have retained a Lean healthcare consultant to help them with timely advice and occasional training.  The consultant keeps them focused on standard procedures, value adding processes and waste elimination and on continuous improvement, all of which are focused on the patient outcomes.  They decide to explore whether they should have their patients who come in for physicals have their blood work done a week before their scheduled appointment.  The office manager asks some of the physicians, nurses and office staff to come together for a few one-hour meetings before the practice opens for patients in the morning.  The goal of this team of volunteers is to assess the pros and cons of having the blood work done before the physical and if so, to develop a standard operating procedure (SOP) for having it done.  Some of the pros and cons are:

• Physicians will be able to discuss with the patients indicators such as triglyceride levels outside of normal ranges so lifestyle changes can be suggested
• Patients who are focusing on improving their health can discuss the results with their physician
• Some patients may find going to a lab before the visit an inconvenience, especially if the lab is in the same building or near the group practice site

Overall, the team decides that they will pilot this approach with two of the physicians.  A SOP is developed involving staff who schedule appointments, nurses aides and physicians.  Indicators of the outcomes in terms of patient health and  physician and staff  attitudes are developed and tracked.
The results of this pilot are positive and the office manager decides to implement the changes for the whole office.  She discusses the procedures with the rest of the staff and physicians and sets up a chart for her use and her staffs’ observation of the rate of compliance with the new procedure.  After a couple of months she finds that there is a lack of progress in improved compliance with the procedure.  Upon further investigation she finds that one of the schedulers and a nurse’s aide are consistently not following through with their procedures.  She talks to them about this and after a couple of months they are still not following their procedures.  What should she do?
According to a recent newsletter of Lifewings, a quality improvement group for healthcare, CEO Steve Harden stated that about 8% of staff of groups who are beginning quality improvement projects at their site will not participate or will actively block projects.  In the newsletter he advises that management have a plan in place to deal with these 8%.  Lifewings trainers get a verbal commitment from management that they will actively engage those who are blocking projects by having a conversation with them and trying to get them to commit to join in the improvement efforts.  Some will agree to but will still not change.  Some will not even agree.  Mr. Harden suggests that managers then ask these staff to find another place to work.  Further, he says to celebrate the achievements of those who have helped improve patient health outcomes through process improvement projects.
Jim Zawacki, co-author of It’s Not Magic, the Rebirth of a Small Manufacturing Company, suggests another approach.  In his book which describes the Lean quality improvement efforts at his company, GR Spring and Stamping, he describes how a team of managers and front line employees came to grips with those who would not join others as they started the cultural transformation necessary to ensure the success of a Lean Process Improvement program.  After the Lean program had been well established the team decided that management would have to ask those who were unwilling to change to leave the company.  Mr. Zawacki as CEO made sure that happened.
If you are just beginning quality improvement efforts at your site, you must come to grips with dealing those who will not join it.  Eventually, they will sabotage much of your efforts and will negatively influence those staff members who are involved.  Management should have a plan on how to consistently deal with the recalcitrant staff, including asking them to find other employment.  Do not let a rotten apple spoil the barrel.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.

Role of Facility in healthcare delivery and Patient Safety

-Dr.Abhimanyu Bishnu, Head of Quality and Senior Manager- Medical Operations and Quality, Aditya Birla Memorial Hospital, Pune;Email- abhimanyu.bishnu@gmail.com
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“Five babies die due to fire in phototherapy unit at a hospital in Punjab” (Jan 2009)

“Patient critically injured after fall from 3^rd floor of hospital in Maharashtra” (Oct 2009)

“30 injured in Hyderabad hospital fire” (Feb 2010)

 “New born abducted from maternity ward of Ahmedabad hospital” (Mar 2011)

These are some of the alarming headlines in recent times. In a healthcare environment that is constantly volatile and increasingly competitive, this is an adverse publicity that these hospitals could probably do without. Which brings us to the fundamental premise that hospitals have to be designed and operated as safe, comxfortable and efficient buildings.

To quote Winston Churchill, “We shape our buildings and afterwards our buildings shape us”. According to Louise Sullivan, “Form follows function.” Today, evidence links patient safety outcomes to hospital design, but it is only in recent times, due to the awareness of accreditation requirements, that hospitals are laying emphasis on facility-related patient safety aspects.

Casualty Room after an emergency

The linkage of hospital structure to the healing process has a historical angle. The very first hospitals, in ancient Greece, Rome, India and Egypt, were part of temples and had a spiritual and medical function. In medieval Europe, too, hospitals had a religious association, and patient wards were designed so as to allow avn unobstructed view of the alter of the presiding diety. Spirituality was considered an important part of the healing process. Later, the pioneering work of Florence Nightingale in sanitation, hygiene and hospital ward outlay during the Crimean War (1854- 1856) led to alterations of hospital facility design, leading firstly to changes in hospital ward design and air flow and later to the multiple bed “Nightingle Ward” as we know it today, which combines utility, grid pattern design, adequate ventilation and optimal use of facilities. Today, as times have changed and patient comfort and infection control have become paramount, we see the popularity of smaller patient bays (4-6 beds) and single rooms.

The important aspects to be considered in hospital design are: 1) Promotion of a healing environment, 2) Enhancement of safety, 3) Promotion of utility and convenience, 4) Infection prevention, 5) Facilitation of an IT-enabled environment, 6) Removal of human and biomedical waste.

A basic framework of hospital facility safety laid down by accreditation agencies such as the Joint Commission International (JCI) includes-

1) General Safety & Security

Guarding of key entry and exit points, visitor identification, close circuit camera monitoring and access control devices are deployed to provide a safe and secure environment, protected from intrusions and unauthorized access. Patient assist devices are used to prevent patient falls in bathrooms, and the floor design element includes the use of anti-skid flooring.

2) Hazardous materials Safety

Exposure to hazardous materials such as formalin, ethylene dioxide, mercury (from broken thermometers/ BP apparatus) represents a serious occupational and health hazard. To counter this, the organization draws up a list of hazardous materials used, along with precautions to be taken while handling, and management of exposure. The materials are classified into inflammables, corrosives and irritants, with due precautions taken for each. The hospital also forms a team, comprising of members from the Security, Engineering and Housekeeping services, which deals with the management of hazardous material spills.

3) Emergency management

Patient collapse, verbal/ physical disputes, abduction of infants etc represent emergencies which have to be dealt with efficiently and swiftly. Specific systems (called Codes , such as Code Blue, Code Purple etc) are set up, with designated personnel, to deal with these emergencies.

4) Fire safety

Healthcare facilities are prone to fire accidents due to factors such as the usage of pure oxygen, anaesthetic gases, multiple electrical equipment, kitchen facilities etc. Hospitals in India need to adhere to the National Building Code, which prescribes– a) Fire detection systems such as manual electric fire alarms, automatic detection and alarm systems and b) Fire suppression systems such as automatic sprinklers, fire extinguishers, hose reels, fire hydrants . Hospitals also constitute a fire safety team, headed by a Fire Safety Officer, managed by Fire Marshals and consisting of hospital security, engineering and other staff, to deal with fire situations.

5) Medical equipment safety

Medical equipments make up the armoury of the modern-day hospital, and regular checking and timely preventive maintenance and calibration of these equipments is a must for ensuring that equipment work well at all times.

6) Utility management safety

Electricity and water are the lifelines of a hospital, and  it is important to ensure that in addition to the primary source, standby systems for electricity such as Diesel Generator ( DG) sets, Uninterrupted Power Supply( UPS) sets and that for water such as borewell or river water supply be kept ready at all times. It is important to provide clean, uncontaminated water, which is vital for processes such as dialysis, endoscopy, invasive procedures. Regular checking and maintenance of biomedical gas supply is also an important part of utility management.

The Institute of Medicine (IOM), in its iconic report,” Crossing the Quality Chasm: A New Health System for the 21^st Century”, has identified the following critical design elements for Patient Safety- Patient centredness, Safety, Effectiveness, Efficiency, Timeliness and Equity. The features deployed by hospitals, mentioned above, would help to achieve these objectives.

The hospital of the future is likely to be a safer and more welcoming place, instead of the intimidating structures of yesteryear. Globally, the transformation is already happening at places like the new Rikshopitalet University Hospital in Oslo, Norway, where architects designed a large facility on a human scale, inspired by the comforting layout of a bright, glass-roofed “street” that gently curves to suggest a village road, with the treatment areas and labs clustered around central courtyards on one side of the street and patient wards on the other side. The hospital provides ample views of nature, incorporates daylight and has used soothing tones for bed areas and energizing shades for physiotherapy, believing that the right environment promotes patient health and well-being.

Interiors are receiving considerable attention in new hospitals in India, and the concept of the Atrium/ Courtyard or public place within the building catching on.

At the under- construction Cleveland Clinic Abu Dhabi (to be opened in 2012), giant cranes move blocks of concrete and place them neatly, piling more layers upon what will be a huge, yet intricately designed landmark construction- a 360 bed (expandable to 490), 24- storied hospital with advanced facilities, positioned to be one of the leading hospitals in the Middle East. The hospital is using a village concept, providing gathering places, indoor water elements, skillfully employed wayfinding elements, sleek glass walls and color-coding. It will deploy displacement ventilation to provide energy saving and infection control, and use alternative and recyclable sources of energy. Inputs for facility safety have been provided by the Quality and Patient Safety Institute at Cleveland Clinic, Ohio.

Nearer home, the Tata Memorial Centre, Kolkata, a newly-designed comprehensive cancer hospital, has employed JCI as a project consultant , and  has received their certification on conformance to Quality and Patient Safety requirements. Many other hospitals in India and abroad are planning to follow suit. Facility Safety is becoming an integral part of hospital planning in India.

From temples of god to abodes of safety and comfort, hospitals have come a long way. This is an era of facility safety and patient comfort that Florence Nightangle, arguably the world’s first Patient Safety Officer, would have been justifiably proud of.