Applying Evidence-Based Design at the New Parkland Hospital
"The new hospital will be a safe, welcoming, patient-centered healing environment that serves as a sustainable community resource for Dallas County. It will promote excellence in clinical care, teaching, and research in a technologically advanced, easily accessible environment.”
With this guiding principle top-of-mind at all times, the design team for the new Parkland Hospital in Dallas set to work to design a hospital for the future. Acknowledging the link between the physical environment and patient and staff outcomes, the design team implemented an evidence-based design (EBD) strategy to translate the project vision into a meaningful and financially sound design and construction plan.
The Center for Health Design (CHD) defines evidence-based design as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” Currently, more than 1,200 research studies suggest healthcare design can improve patient care and medical outcomes, decrease medical errors and waste, and increase patient and staff satisfaction. As a result, the Parkland team recognized that an exceptional healing environment is one that embraces patients, visitors, and staff while supporting them during the time they are in the facility.
To successfully implement EBD principles, the Parkland design team sought to create an environment of care that incorporates streamlined processes, new technologies, and nurturing design elements. A visioning session was held involving all stakeholders in the project to identify proven strategies that would:
• Improve patient safety;
• Improve patient outcomes;
• Increase patient, family, and staff satisfaction;
• Improve efficiency and effectiveness of staff; and
• Accommodate today’s best practices, with flexibility to adapt to the future.
Below are the specific EBD principles that have been identified for the new Parkland Hospital, along with their corresponding design interventions.
Improve patient safety
To reduce patient falls and injuries, slip-resistant flooring is being specified, especially in patient bathrooms, which are large and ADA compliant. Walk-in showers do not have curbs, which might cause a patient to stumble. Clear paths to restrooms and night lights in patient rooms and bathrooms decrease opportunities for falls. Additionally, patient lifts are provided in many rooms to assist caregivers when moving patients.
All patient rooms at Parkland are private, which helps to reduce the risk of hospital-acquired nosocomial infections. Highly visible and ample hand sanitizers are being placed throughout the facility. In addition, a caregiver sink is being provided at the entrance to each room. The use of HEPA filtration systems in patient rooms, emergency exam rooms, and other zones will help protect the most vulnerable patients. Antimicrobial flooring and fabrics reduce the spread of germs.
Improve patient outcomes
Parkland’s patient units feature decentralized caregiver workstations between every two patient rooms, as well as visual access into each room, which increases observation capabilities and allows for a higher level of care. In addition, some supplies and equipment are being decentralized to the patient room, limiting the amount of time the caregiver spends on fetching supplies and equipment and enabling more time on direct care. Bedside bar-coding and a bedside computer terminal also increase staff efficiencies.
Parkland also has committed to building acuity-adaptable patient rooms for all areas (ICU, medical/surgical, postpartum, rehabilitation, and mental health). Universal, acuity-adaptable, variable acuity, and transitional care are terms used interchangeably to describe a patient care model concept. This concept supports the position that the patient remains in the same room for the duration of his/her stay and the staffing level is adjusted according to the acuity of the patient.
Parkland chose to use these rooms because evidence demonstrates they reduce transfers of patients, result in fewer handoffs between caregiver teams (limit treatment delays and opportunity for errors), eliminate delays for placement of patients, reduce the need for equipment duplication, reduce complications, and decrease a patient’s length of stay. Hospitals with acuity-adaptable patient rooms also report fewer staff injuries resulting from transferring patients.
Additionally, a dedicated family area in each patient room encourages family members to participate in the caregiving process, which often leads to better outcomes because the family understands how to better care for their loved ones once they are dismissed to home.
Increase patient, family, and staff satisfaction
One of the ways Parkland seeks to increase the satisfaction of patients, visitors, and staff is to reduce stress through environmental noise control. For example, extensive use of “on-stage/off-stage” design defines separate corridors and elevators for visitors and staff. This lessens foot traffic and, along with sound attenuation between rooms, significantly reduces noise in patient care areas, ultimately promoting a more peaceful healing environment. Finishes have also been chosen to absorb sound.
The dedicated family space in Parkland’s private patient rooms is generous, allowing for rooming-in capability. It is located nearest the window and away from the entrance to the room so staff members have clear access to the patient from the hallway. Caregiver space inside the patient room is between the doorway and the patient bed. This fosters enhanced privacy for the patient because caregivers will be turned away from the door and toward the patient and the family when discussing care.
Another amenity is individual temperature control, allowing patients to control the comfort level within their own room. Soft lighting and soothing artwork alleviates restlessness and can help lessen dependence on medications. High-end furnishings also foster an inviting, homelike atmosphere.
Several studies have shown that views of nature are significantly effective in promoting recovery by decreasing depression, lessening agitation, and promoting sleep cycles and quality of sleep. There is increasing evidence that exposure to nature is especially beneficial in fostering restoration for stressed patients, family members, and staff. As a result, Parkland’s patient rooms have large windows for unobstructed natural views and an abundance of sunlight. Large windows are also in staff work areas and procedure rooms, strengthening the con
nection with the outside world.
Patients, guests, and staff also will have access to well-designed healing gardens that not only provide calming and pleasant nature views, but also can foster access to social support and privacy while providing opportunities for escape from stressful clinical settings. Many healthcare employees use gardens as a restorative escape from work stress.
Based on research, post-occupancy evaluations, and other feedback, Parkland’s gardens are being designed to provide a variety of types of spaces for different user groups, with privacy from others and views from the building. Some areas will accommodate groups, while others will be dedicated to private contemplation. In addition, a looping and easily navigated circulation pattern will provide opportunities for exercise. Finally, a wide variety of plant material and water features will afford positive distractions.
Improve efficiency and effectiveness of staff
Healing environments not only contribute to patient wellbeing, but also to the wellbeing of the physicians, nurses, facilities staff, and administrators who work in the building. These positive work environments contribute greatly to improved staff recruitment and retention—two critical factors as the healthcare field faces labor shortages.
Parkland has chosen to use same-handed rooms, which feature an identical, repeated layout. This type of layout means the patient bed, technology, caregiver space, family space, washroom, and handwashing sink are in the same location in every patient room. However, initial discussions regarding same-handed rooms underscored some concerns whether the merit outweighed any additional cost.
To help with the decision-making process, the design team held a teleconference with staff from other hospitals that use same-handed rooms. (Participants included representatives from CHD; Denver Health & Hospital Authority, Denver; St. Mary’s North, Powell, Tennessee; New Hanover Medical Center, Wilmington, North Carolina; Wheaton Franciscan Hospital, Franklin, Wisconsin; Dublin Methodist Hospital, Dublin, Ohio; Central Washington Hospital, Wenatchee, Washington; and St. Joseph Hospital, West Bend, Wisconsin.)
Existing users reported that staff found it easier to work in same-handed rooms because there was less confusion about where equipment was located. This is especially important during crisis situations when staff from various areas converge in one place to handle the emergency. The ease of orienting float staff, residents, and medical students who are on a particular unit for one day to six weeks and then rotate somewhere else was also reported as a benefit. Two managers mentioned that they believed same-handed rooms were a recruiting tool because they were so easy to work in.
In the end, Parkland committed to building all same-handed patient rooms. In addition, emergency department exam rooms, labor and delivery rooms, and surgery suites are also same-handed.
Each patient floor will accommodate two 36-bed units, built end to end with nursing alcoves tucked along the 300-foot-long hallways. No centralized nurses’ stations will be located in patient units; decentralized stations mean less walking for staff. Each unit will have team rooms for collaborative care discussions and a relaxing lounge for staff interaction.
Accommodate today’s best practices, with flexibility to adapt to the future
It’s difficult to know what the future of healthcare will be five years from now, let alone 50 years. Constant advances in medical diagnostics and treatment modalities, along with their associated technologies, means hospitals must have the capability to adapt to these changes efficiently and with minimal investment. That’s why the new Parkland has to be able to grow and change to meet the future medical needs of its community.
Designers and planners can accommodate this need by designing in flexibility, such as modular units and acuity-adaptable rooms. The facility also will be sustainable, utilizing green building methods and energy sources, as well as environmentally friendly building materials.
The evidence-based design process
While it’s not uncommon for those working on hospital projects to solicit the advice of medical professionals and patients, Parkland has created a unique nurse liaison team to help ensure every detail of this large project is focused on patient care. Valuable clinical input comes from the creation of mock-up rooms (See Figure 3), which are true-to-size models of patient care areas, including patient rooms, an operating room, intensive care exam room, trauma room, labor and delivery suite, visitor elevator, neonatal intensive care room, and emergency exam room.
Also essential to the project is the patient and family advisory committee. This group of former Parkland patients and families of former Parkland patients meets regularly with the design team to test new ideas and define best practices in the eyes of the patient. Once clinical and patient input is integrated into the rooms, nursing staff return to practice mock medical codes and procedures in the mock-up rooms to assure the design is functioning at its highest level. The process also reassures Parkland nurses and clinical staff that the design team is looking out for their patient care needs.
CHD’s Pebble Project research initiative also provides examples of healthcare organizations whose facility design has made a difference in the quality of care–as well as their financial performance. As a Pebble Project partner, the Parkland Hospital case study will be mined for data to demonstrate that facility design can: improve the quality of care for patients; attract more patients; recruit and retain staff; increase philanthropic, community, and corporate support; and enhance operational efficiency and productivity. HCD
Kathy Harper, RN, MBA, EDAC, is Director of Clinical Planning at Parkland Health and Hospital System. Hank Adams, AIA, ACHA, EDAC, is Healthcare Principal, and Dan Thomas, AIA, EDAC, is a Senior Healthcare Designer at HDR Architecture. For more information, visit www.parklandhospital.com/newparkland.