Safety by
designPerioperative nurses can share their practice
knowledge to inform OR design that maximizes efficiency and patient
safety
By Carina
Stanton
Senior News Editor
While the down economy has delayed some new healthcare construction projects across the country, perioperative nurses are still playing a critical role in the successful planning and development of current and future healthcare construction projects that include perioperative areas.
Surgical facilities are often the most costly areas to build in a healthcare facility, so working with perioperative nurses to understand daily practice and clinical practicalities is critical to creating a successful perioperative environment, according to Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices in AORN's Center for Nursing Practice.
"As we all look for ways to optimize efficiency and reduce unnecessary financial output, it is more critical than ever that nurses and other users in healthcare facilities are part of the team to help make certain that no wasteful errors in design are made, because facilities can't afford a redo, especially in surgical areas," Conner said.
Design in action
Leading a design project often means wearing many hats, said Janet Remizowski, RN, BSN, MSHA, clinical director of the University of Rochester Surgery Center in Rochester, N.Y., which is slated for opening in early August.
Providing the perioperative perspective
Vicky Petalas (right), a certified central service surpervisor,
reviews plans with Ralph DiTucci, owner of the
University of Rochester Surgery Center in Rochester, N.Y.,
as they stand in what will be a sterile processing area in the new facility.
Source: Janet Remizowski
Remizowski has been involved in each step of the facility's construction, from design review, to equipment planning, construction, and now staff education and facility set-up. She said planning processes for all aspects of patient care is the primary focus in healthcare design, especially in an ambulatory surgery center where different steps of perioperative care often happen in the same space.
"Efficiency is critical. Often we walk through scenarios to determine how a situation may play out," she said. "The scenarios we practice are patient flow to make sure that the constructed space will promote efficient traffic flow from admission to discharge." Remizowski said efficiency is an important focus in an ambulatory setting because there are not as many hand-offs to different staff in comparison to those in inpatient setting.
"Efficiency is often confused with fast, but efficiency, when combined with communication and adherence to standards, really improves patient safety." In other scenarios her design team considers is how the facility design will accommodate unexpected events. For example, say an instrument is dropped and needs to be sterilized and brought back to the surgical field. "You need to design placement of the autoclave to accommodate this scenario in the most efficient, streamlined way," she said.
"Don't forget the essential component of adequate planning for sterile processing within a facility's design," stressed Deb Spratt, RN, BSN, MPA, CNOR, NEA-BC, clinical director of perioperative services at the University of Rochester Medical Center's Highland Hospital in Rochester, N.Y., and secretary of AORN's board of directors. "No facility should rely on flashing," Spratt said. "Budgeting for enough instrumentation and constructing a fully functioning sterile processing department that is integrated well within the facility should be part of any good perioperative construction project."
Spratt works with Remizowski and advises on both the free standing and in-patient sides of healthcare design. Through this work she collaborates with the New York State Department of Health on the practical applications of the American Society of Healthcare Engineering Guidelines for Design and Construction of Health Care Facilities, which is published by the American Institute of Architects (AIA).
Spratt and Remizowski agree that an important part of designing safe perioperative areas is to focus on staff safety, as well as patient safety. Perioperative ergonomics is an important issue Remizowski and Spratt both address as part of healthcare design. One important resource they turn to for guidance on perioperative ergonomics is AORN's guidance statement on Safe Patient Handling and Movement in the Perioperative Setting, especially when they are planning equipment for a facility.
For example, Remizowski's facility is designed with booms to lessen the need for perioperative staff to move heavy equipment and stretchers, which convert to a recliner position. This feature eliminates the need for a nurse to transfer a patient to a chair.
Both encourage collaboration with vendors, who can often provide three dimensional depictions of scenarios in the perioperative setting to help plan the most efficient design. Remizowski also said that for ambulatory surgery centers, it is valuable to collaborate with vendors and in-patient facility staff to get group purchasing discounts on equipment.
"The key to successful healthcare design is strong communication and collaboration among the design team and users, so there is a clear understanding of needs, expectations, space usage and every step of the patient care process in the new facility," Remizowski said.
Bridging the gap
When planning a new construction project or a redesign, nurses can serve as valuable liaisons between architects, vendors and other members of the design team to ensure that the realities of everyday practice are realized in the design.
"We speak the same language as the healthcare facility leaders. We can help bridge the gap to help designers understand what nurses and other surgical staff will need and how they will be moving in the design space," said Robin Allen, RN, BS, CNOR, a former perioperative director who currently is a medical equipment planner for the medical technology group that is part of HKS, Inc., an architectural firm in Dallas, Texas that specializes in healthcare design.
She said making the leap from managing an OR to helping design healthcare facilities is not necessarily a conventional career move, but the clinical knowledge and understanding for how nursing staff members use their work space makes her uniquely qualified to help ensure a newly built or newly redesigned healthcare facility is fully functional, efficient and safe.
Allen and other members of HKS, Inc.'s medical technology group ideally become involved in design projects during the schematic design process, because equipment like C-arms, booms, imaging machines and other large pieces of equipment need to be planned as the project is designed.
"As technology advances and more and more perioperative areas are built as hybrids to accommodate different services, OR suites must be designed in a way that supports good traffic flow, infection control and efficient turnover time to prevent bottlenecks," said Deb Garner, BSN, MSA, CNOR, a nurse clinical specialist who works with Allen as a medical equipment planner. "This process is a collaborative effort among architects, vendors, staff, infection control experts and specialty consultants, because so many different needs must be considered to make a space fully functional."
A collaborative design team
While Allen now works on the design team hired to help healthcare facilities, she first became involved with healthcare design as surgical services operations director at Alegent Health System, Mercy Hospital in Council Bluffs, Iowa when her facility asked her to work with designers on planning a new construction project at the facility.
As a team leader on the project, she was responsible for building a staff design team to share needs and make decisions about how perioperative areas and other areas of the facility would be constructed.
Users must be brought into the decision making process early on, because they are the ones who know how surgeons, anesthesiologists and other staff will realistically use the space. They also can advise on things like traffic pattern review for patients and staff and supply management that are to some degree unique to the organizational culture of the facility, Allen stressed.
She emphasized the need for staff members of design teams to be open minded to new ways of doing things and resist trying to have the newly built environment mirror the previous space, because that is what people are used to.
"Members of healthcare facility design teams must be able to think futuristically and outside of the box, while also having a clear understanding of the regulations, recommended practices and building guidelines required to build safe and efficient healthcare environments," said Terry Ritchey, RN, BSN, MBA, vice president at HKS, Inc. Ritchey formerly served as chief nursing officer at Parker Adventist Hospital in Parker, Colo. Today she leads the Clinical Solutions and Research group for HKS, Inc.
"Nurses can serve in many different roles on healthcare design projects, whether the facility is planning new construction, renovation or simply wanting to optimize operational efficiencies in their current facility. It is important to identify and eliminate operational inefficiencies and bottlenecks and outline ideal operations and workflows before design begins. This thoughtful planning helps owners make the best use of their capital and human resources," explained Ritchey.
The Clinical Solutions and Research group Ritchey works with at HKS includes clinicians and experts in healthcare architectural design and medical planning. They work as a team with healthcare facilities through all steps of the design process, from early planning, through construction and move-in.
Ritchey said this early planning step of the process is critical, because this is the time when the design team comes to understand the organization's culture, operational processes, technology and information systems, which all inform design.
"Facilities are learning that it pays to be flexible when planning how to use space for surgical services, including hybrid OR suites that can accommodate procedures such as cardiac surgery and catheterization in the same room under standardized conditions. Flexible use of space in prep and recovery also helps organizations save time, money and often improves patient flow," Ritchey said. "We also focus on patient and peer-to-peer visibility to enhance safety. Patient safety is at the root of everything we do."
Understanding safe design
Within OR design, careful planning of the restricted, semi-restricted and unrestricted zones is a critical element to ensure infection control, efficiency and safety. That's why HKS works closely with perioperative experts like AORN's Conner and the American Institute of Architects to understand and translate the need for the specific functions of the OR areas that must be located appropriately.
"The challenge in designing any OR is to place these zones in a way that promotes good traffic flow for patients, staff, vendors and other visitors, while maintaining infection control, and adhering to all safety standards and recommended practices," Conner stressed.
This diagram shows a clean core concept combined with a sub-sterile design concept. The blue area is restricted, the pink area is semi-restricted and the green area is unrestricted. Source: HKS, Inc.
The tricky part is making access to these different zones and adjacent areas such as recovery, imaging, and critical care, be intuitive as part of the design, so you can protect restricted areas while accommodating work flow, added Allen.
One key source that anyone working on healthcare design should be familiar with is the Guidelines for Design and Construction of Health Care Facilities, published by the American Institute of Architects. The updated guidelines will be published by the American Society of Healthcare Engineering (ASHE) in 2010.
The guidelines outline the construction requirements for healthcare design and construction, said Conner. She currently serves as AORN liaison to the ASHE Healthcare Guidelines Revision Committee (HRGC) that develops the guidelines. She was also recently appointed to the HRGC steering committee.
"States adopt all or part of the guidelines as building code regulations," Conner added. "In some cases, there may be more stringent requirements, so all individuals involved with healthcare design should be familiar with state building regulations."
Additional Resources
Articles on healthcare design and design management also can be found through the:
Center for Healthcare Design
AORN Journal
Journal of Nursing Administration
AORN Journal is currently seeking manuscripts on healthcare design. Contact aornjournal@aorn.org for more information.
Read more news in AORN Connections.