St. Josephs Community Hospital identified a unique chance to design a breakthrough replacement facility. With a new facility set to begin construction soon, St. Josephs, located in West Bend, WI, decided to get off on the right foot in its design. Inspired by the Institute of Medicine book, To Err Is Human1, we recognized the opportunity to increase patient safety and promote a patient safe culture through facility design. According to the book, 44,000-98,000 people a year die in hospitals from preventable medical errors. This means there is one death in every 343-764 admissions. The book also claims an adverse event occurs once in every 27-34 admissions. In comparison, aviation averages one death for every 8,000,000 flights.
In April 2002, our approach to address the issue was to bring together leaders in healthcare and systems engineering to create the National Learning Lab (NLL) and ultimately formed the National Advisory Committee (NAC) in 2006. The NLL and NAC developed a set of safety-driven facility design recommendations and principles that guide the design of a hospital facility focused on patient safety. The NLL and NAC generated four sets of recommendations: latent conditions, adverse events, safety culture, and safety design processes.
As we embraced this unique opportunity to increase patient safety and promote a patient safe culture, several challenges became apparent:
X Recognition that the need for safety is endemic.
X Just Culture is an essential ingredient.
X Group process is mandatory.
X Each of the stakeholders approaches the facility development process with a different set of expectations, although many are overlapping.
X Leadership.
X Understanding NLL Recommendations and realizing stakeholders contributions.
X Achieving buy-in from medical staff and board of directors.
X Safety culture takes a whole village.
X Keep the flywheel spinning. To paraphrase Steven Covey, the Safety Flywheel requires some attention to keep it spinning.
X Technology V friend or foe. Embracing new technology in the new hospital has benefited the organizations safety culture, including making clinical information immediately available.
X Tools. Given the number and breadth of the studies, and the fact that previous studies did not exist in many areas, tools were developed specifically for these studies without rigorous testing of the tools themselves.
Studies on eight latent conditions, nine adverse events, and three outcome measures were undertaken prior to the new hospital and Epic implementation, and through the grant study period. The method analysis utilized mixed methods such as surveys, direct observations, interviews, focus groups, and chart audits. In addition, routine hospital data was reviewed, such as incident reports, financial data, and patient satisfaction reports.
The conclusion or outcomes achieved deliver a resounding answer - IT WORKS! The NLL and NAC recommendations had a powerful effect and are influencing hospital facility development, culture and processes -- both nationally and internationally. St. Josephs fully implemented the recommendations of the NLL and the proactive use drove design methods to design out system failure and design in quality of care.
The safety focused design of the new hospital as well as Epic implementation had a positive impact on latent conditions. Key adverse events (medication errors, fall, and infections) were dramatically lowered. The interplay between safety culture, management focus, process change, facility design, and Epic all contribute to the impact on adverse events.
In order to improve quality and safety, these NLL and NAC recommendations and design methods are substantive. By introducing the NLL and NAC safety-driven innovations into the facility design process, environmental designers and healthcare leaders can -- and should use these recommendations to make significant contributions to patient safety. If we change our buildings, our buildings will change us.