Personalizing, Humanizing and Demystifying the Healthcare Environment

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Personalizing, Humanizing and Demystifying the
Healthcare Environment

• Susan B. Frampton, PhD
• President
• Planetree

Hospitals for a Healthy Environment In Rhode
Island March 10, 2011
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Learning Objectives

• Industry changes supporting patient-centered
  environments of care
• Defining features of patient centered
  environments
• Recognizing impact of the built environment
• Making the connection to quality and safety in
  healthcare facilities

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How it all began

• It may seem a strange principle to enunciate as
  the very first requirement in a Hospital that it
  should do the sick no harm.
• -Florence Nightingale, 1859

Royal Victoria Hospital (courtesy Notman
Collection, McCord Museum).
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Hospitals in the Modern Era

• Specialty Hospitals
• Outpatient Services
• Technology Surge
• Efficiency at the expense of
• compassion

Cleveland Clinic, Cleveland, Ohio
New York Presbyterian Hospital, New York, New York
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Patient-centered Principles

• A patient is an individual to be cared for, not a
  medical condition to be treated . . .
• Each staff member is a caregiver . . .

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The new accountability for patient-centered care

• establish a Hospital Value-Based Purchasing
  (VBP) program in Medicare that moves beyond
  pay-for-reporting on quality measures, to paying
  for hospitals actual performancebeginning in
  FY2012measures would focus on heart attack
  (AMI) heart failure pneumonia surgical care
  activities and patient perception of care.
• Language included in the Affordable Care Act

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CMS Transition to Value Based Purchasing

• Transition from pay-for-reporting to
  pay-for-performance
• Current 100 payment for reporting
• 2011-2012 Data Collection/performance year
• 2012-2013 Hospital payments adjusted based on
  performance
• 1 in FY13, 1.25 in FY14, 1.5 in FY15, 1.75 in
  FY16, 2 in FY17
• HCAHPS 30 of overall VBP score (combination of
  actual scores and improvement from baseline to
  current year)
• CMS Core Measures 70

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Patients are Choosing Based on Experience
What factors are the influence on your choice
of hospitals?
Valued Patient Experience

• Keeping patients informed
• Being on time
• Room appearance furnishings
• Ease of scheduling
• Food and entertainment in room

• Value for money
• Simple registration access to records
• Ease of understanding bill
• Environment supporting family needs
• Convenience comfort in common areas

Source McKinsey Survey Results (gt2000 patients)
reported in The McKinsey Quarterly, November 2007
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The Patient Perspective

• Compassionate Human Interactions
• Access to Meaningful Information
• Support Participation of Family, Friends
• Healing Environments
• Support for Mind, Body and Spirit
• Arts and Entertainment
• Spirituality
• Caring Touch
• Integrative Therapies
• Healthy Food and Nutrition
• Healthy Communities

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Designing Environments to Support
Patient-Centered Care
Family Presence Access to Information Involvement
in Decision Making Effective Communication Respect
ful Interactions Foundation for Quality and
Safety
Massage Music Clowns Fish Tanks Cookies Dogs
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Identifying the challenges (and some solutions)
www.iom.edu
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Patients View Poor Service and Substandard
Environment as Unsafe

• 22 of 193 reported a recent unsafe experience
• More than half of the events were classified as
  service quality incidents
• 30 related to waits and delays
• 21 related to poor communication
• 12 related to environment factors
• Conclusion Patients may perceive that these
  inconveniences signal problems with the overall
  process of care
• Source Patient-Reported Safety and Quality of
  Care in Outpatient Oncology, Joint Commission
  Journal on Quality and Patient Safety 332, 2007

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and Theyre Right!

• Do Medical Inpatients Who Report Poor Service
  Quality Experience More Adverse Events and
  Medical Errors?
• Med Care. 2008 Feb46(2)224-228.
• CONCLUSIONS Patient-reported service quality
  deficiencies were associated with adverse events
  and medical errors. Patients who report service
  quality incidents may help to identify patient
  safety hazards.

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What symptoms of poor design in health care
facilities could contribute to medical errors?

• Virtually any characteristic of the environment
  can have a supportive or detrimental effect on
  human performance and hence, on patient safety.
• Kenneth N. Dickerman and Paul Barach, Designing
  the Built Environment for A Culture and System of
  Patient Safety A Conceptual, New Design Process
  in Advances in Patient Safety, in Agency for
  Healthcare Research and Quality, New Directions
  and Alternative Approaches, Volume 2 Culture and
  Redesign, 2008.

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Making Connections

• Elements of design can help establish
  connections between patients and providers

Outpatient Surgical Room, Waverly Health Center
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Infection Prevention

• In a survey of health care workers, 75 percent
  stated that rewards or punishments would not
  increase hand-washing, but 80 percent said that
  easy access to sinks and hand-washing facilities
  would.
• Keeping Patients Safe Transforming the Work
  Environment of Nurses 2004

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Infection Prevention
Infections can also be reduced by providing
multiple locations for staff members to wash
their hands so they spend less time walking to
sinks and have more opportunities to sanitize
their hands before providing care. Agency for
Healthcare Research and Quality Transforming
Hospitals Designing for Safety and Quality 2007
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Patient Falls

• The majority of falls of hospitalized patients
  occur in the patients room, usually in
  association with elimination needs.
• Keeping Patients Safe Transforming the Work
  Environment of Nurses 2004

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Design and Fall Prevention

• Patient falls can be avoided. Poor placement
  of handrails and small door openings are two
  primary causes of patient falls. Many falls can
  be reduced through providing well-designed
  patient rooms and bathrooms and creating
  decentralized nurses stations that allow nurses
  easier access to at-risk patients.
• Agency for Healthcare Research and Quality
• Transforming Hospitals Designing for Safety and
  Quality 2007

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Lack of Storage Space

• Because of a lack of adequate storage space,
  medication carts, wheelchairs, isolation carts,
  and dietary carts are often found in the hallway,
  blocking travel for both patients and caregivers
  and introducing safety hazards (falls, fire,
  public access to medications and supplies) in the
  environment.
• Keeping Patients Safe Transforming the Work
  Environment of Nurses 2004

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Challenge the False Choice between Patient Safety
and Design

• Soft Suicide
• Prevention Door
• National Association of Psychiatric Health
  Systems, Design Guide for the Built Environment
  of Behavioral Health Facilities Edition 3.0
  (2009)

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Safe Involvement of Family/Friends in the ICU
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Key Factors in Personalizing the Healthcare
Environment

• Privacy
• Noise Control
• Views and Access to Nature
• Wayfinding
• Therapeutic Distractions

Griffin Hospital Photo courtesy of S/L/A/M
Collaborative, Inc.
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Privacy
Midwest Medical Center Photo courtesy of Earl
Swensson Associates, Inc.

• Patient rooms
• Registration
• Family Consult Rooms
• Staff spaces

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Single Bed Rooms are Better Medicine

• Single-bed rooms and improved air filtration
  systems can reduce the transmission of
  hospital-acquired infections
• -Agency for Healthcare Research and Quality 2007
• Better communications, reduced transfers, fewer
  medication errors, decreased infection rates, and
  comfortable inclusion of the family
• - Hendrich 2004
• Single patient rooms decrease the risk of
  hospital-acquired infections
• - Chaudury, Mahmood, and Valente 2003

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Noise, Stress and Healing
Impacts of high noise levels on staff
Increased perceived work pressure, stress, and
annoyance Increased fatigue Emotional
exhaustion and burnout Difficulty in
communication possibly leading to errors
Impacts of high noise levels on patients
Annoyance Sleep disruption and awakening
Decreased oxygen saturation, elevated blood
pressure, increased heart and respiration rate
among neonatal intensive care patients
Decreased rate of wound healing Higher
incidence of re-hospitalization
Source Anjali J. and Ulrich, R., The Center for
Health Design, funed by a grant from the Robert
Wood Johnson Foundation. Issue Paper 4, January
2007
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Staff Stress

• Walking
• Fatigue
• Noise
• Access to support functions

Valley View Hospital, Glenwood Springs, Colorado
Banner-Page Emergency Department Photo courtesy
of Smith Group, Inc.
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Control of Noise

• Decentralization of nursing stations
• Materials (ceiling, flooring, doors)
• Carts and equipment
• Overhead paging

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Music

• Music decreased the use of analgesics and
  hastened recovery from surgery in a study of 90
  hysterectomy patients -
  Nilsson, et al., 2001
• Music programs timed to a surgical procedure
  produced significant reduction in the amount of
  perceived pain and decrease in the level of
  stress hormones in the blood -
  Robertson, 2001
• Studies of neonates also provide strong evidence
  for the benefits of music to promote weight gain
  and reduce stress, resulting in a shorter length
  of hospital stay
  - Caine, 1991

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Patient Music Survey
1. This was my first chemotherapy
treatment. 2. My anxiety level was very
high. 3. I have used music for relaxation
before. 4. The music was soothing. 5. The
music helped me relax.
Data from a survey of 73 cancer patients At
Shands AGHospital
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Music is a moral law. It gives a soul to the
universe, wings to the mind, flight to the
imagination, a charm to sadness, and life to
everything. Plato
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Access to Nature
Photo courtesy of Alliance Community Hospital

• Daylight
• Gardens
• Therapy Patios and Gardens
• Dining Areas

Photo courtesy of Loma Linda University Medical
Center
Kadlec Medical Center Designed by Sara Nelson
Design artwork by Herb Leonhard
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Improve Wayfinding

• Reduce stress
• Provides for welcoming, friendly environment
• Common verbiage multi-lingual
• Architectural and art cues

Photo courtesy of Sharp Coronado Hospital
Photo courtesy of North Valley Hospital
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The Healing Power of the Arts

• The excellent staff has nourished my body
• The flowers and art have nourished my soul
• I am not confined to these four walls
• My eyes rest on a water color of Marin Beach
• I step through the frame
• Walk hand in hand with peace and serenity
• And therein lies the healing.

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Therapeutic Distractions
Photo courtesy Alegent Health System - Lakeside

• Artwork positive scenes
• Outdoor views
• What the patient sees
• Respite areas

Photo courtesy of Waveryly Medical Center
Photo courtesy of Kadlec Medical Center
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Positive DistractionsHumor and Entertainment

• Health benefits of a good laugh include
  greater optimism, socialization and cooperation
  among patients decreased dependence on
  tranquilizers and pain-relieving medication and
  less burnout among health professionals
  - Fry WF, 1992
• Exposure to a humor video resulted in decreased
  levels of epinephrine (adrenaline)(raises the
  heart rate and blood pressure) and cortisol
  (suppression of the immune system).

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Smells

• Unpleasant odors stimulate anxiety, fear and
  stress.
• Pleasing aromas reduce blood pressure, slow
  respiration and lower pain perception levels.
• Pleasant fragrance lowered patient-rated anxiety
  during magnetic resonance imaging - Redd, et
  al.,1994

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Patients Can Tell the Difference

• A recent study found that hospitals in the
  highest quartile of performance on the HCAHPS
  hospital environment questions (clean/quiet) had
  a lower incidence of selected infections due to
  medical care.
• The Relationship Between Patients
  Perception of Care and Hospital Quality and
  Safety Thomas Isaac, MD, MBA, MPH Alan M.
  Zaslavsky, PhD Paul D. Cleary, PhD Bruce E.
  Landon, MD, MBA presented at CAHPS User Group
  Meeting December 2008 (available at
  https//www.cahps.ahrq.gov)

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The Proof
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Planetree Designation Program

• Designated Patient-Centered Hospitals
• Centre de réadaptation Estrie, Quebec
• Delnor Hospital, Illinois
• Fauquier Hospital, Virginia
• Flevoziekenhuis, The Netherlands
• Griffin Hospital, Connecticut
• Longmont United Hospital, Colorado
• Mid-Columbia Medical Center, Oregon
• Northern Westchester Hospital, New York
• Sharp Coronado Hospital and Healthcare Center,
  California
• Valley View Hospital, Colorado
• Waverly Health Center, Iowa
• Windber Medical Center, Pennsylvania
• Designated Resident-Centered Communities
• De Merlinge, Netherlands
• Judith Leysterhof, The Netherlands
• The Toonladder, The Netherlands

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Patient-Centered Hospital Designation Program

• Recognition program for hospitals, behavioral
  health facilities and long-term care communities
  that have implemented patient- and
  resident-centered care in a comprehensive manner
• Recognized by Joint Commission on Quality Check

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Designation Criteria Domains

• Healing Environment Architecture and Interior
  Design
• Arts Program/ Meaningful Activities and
  Entertainment
• Spirituality Diversity
• Integrative Therapies/ Paths to Well-Being
• Healthy Communities/ Enhancement of Lifes
  Journey
• Measurement

• Structures and Functions Necessary for Culture
  Change
• Human Interactions/ Independence, Dignity and
  Choice
• Patient/Resident Education and Community Access
  to Information
• Family Involvement
• Nutrition for Healing

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Healing Environment Criteria

• VI.G The organization is able to demonstrate
  sustainable and green approaches to
  construction and renovation and promotion of
  environmentally-friendly practices in the
  operation of the facility.

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CMS Core MeasuresComparison of U.S. Planetree
Designated Hospital Average and CMS National
Average January 2009-December 2009
Source The Commonwealth Funds
WhyNottheBest.org Data accessed 11.01.10
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Planetree performance is significantly better
than the national average at the 90 confidence
level Planetree performance is significantly
better than the national average at the 95
confidence level
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THANK YOU!

• Susan B. Frampton, PhD
• President
• sframpton_at_planetree.org