Using an integrative mock-up simulation approach for evidence-based evaluation of operating room design prototypes

Enhancing healthcare operations: a systematic literature review on approaches for hospital facility layout planning

PURPOSE

The appropriate physical layout of hospital services can help resolve management problems by streamlining the work of medical teams, improving the flow of patients between specific areas and the medical support environment. Nevertheless, the academic literature lacks structured research into how the physical layout of hospitals might be improved. Our study aims to fill this research gap, providing information for researchers and professionals who intend to guide the hospital facility layout planning (HFLP) from the steps and prescribed approaches found in the literature.

DESIGN/METHODOLOGY/APPROACH

This study analyzes the current literature status and concerning approaches that support HFLP and identifies their strengths and weaknesses. The literature was classified using the following criteria: approaches for layout generation, approaches for layout evaluation and healthcare facility layout outcomes.

FINDINGS

The hospital facility layout outcomes achieved for each phase served as a basis for identifying a list of strengths and weaknesses for the hospital layout facility generation and evaluation approaches. Readers can refer to this paper to identify the approach that best fits the desired goal and the HFLP step.

PRACTICAL IMPLICATIONS

This is a contribution to current studies into HFLP, and it provides guidelines for selecting the approach to be utilized based on the desired outcome.

ORIGINALITY/VALUE

The paper describes how to conduct an HFLP and lists the strengths and weaknesses of each approach. The research may be used as a strategy for determining which tool is most suited based on the practitioner's target purpose.

Lessons learned from implementing a Human Factors programme into an NHS trust

The interest in employing Human Factors (HF) in healthcare is increasing. There are very few papers that outline an approach to embedding the practical application of HF in healthcare and the lessons that can be learned. The SCReaM HF and Team Resource Management (TRM) programme is not only aimed at raising the awareness and understanding of the science of HF within healthcare, but also to embed its practical application to support staff improve their safety and wellbeing and that of their patients. The programme is divided into three strands: rolling training, HF Projects and HF Engineering. Each strand of the programme supports the use of HF by teaching and applying systems thinking methodology. The programme has been embedded into an NHS Trust and this paper provides a reflection on the approach used to help guide future attempts to integrate HF into an NHS trust.

Caring for those who care: key challenges and improvement opportunities for health professionals working with children with disabilities

This paper investigates the challenges faced by health professionals working with children with disabilities, with the aim of identifying areas for improvement. Employing a focus group method, the study involved knowledge levelling, discussions, problematization, cause formulation, and validation. A diverse team of ten professionals participated, including physiotherapists, speech therapists, occupational therapists, psychologists, nursing technicians, and social workers. Findings reveal organisational inflexibility in appointment scheduling, lack of deadlines affecting case monitoring, and the mental strain of immediate clinical responses. Effective communication and multidisciplinary care emerge as beneficial. Proposed improvements include flexible space utilisation, enhanced room design, structured collaboration training, role clarification, parent partnerships, flexible scheduling, and continuous professional development. This study unveils unique challenges and rewards in the healthcare environment, offering insights into causative factors and practical strategies for enhancing the work of health professionals working with children with disabilities.

A knowledge framework for the design of built environment supportive of resilient internal logistics in hospitals

Internal logistics is crucial for hospitals, occurring within facilities that pose constraints and opportunities, demanding resilient performance (RP) to adapt to dynamic conditions and balance safety and efficiency pressures. However, the role of the built environment (BE) to support RP is not explicitly analysed in the hospital logistics literature, which is usually limited to discuss BE in terms of layout and routing issues. To address this gap, this study presents a knowledge framework of BE supportive of RP in internal hospital logistics. The framework was developed based on a study in a large teaching hospital, encompassing 11 service flows of people and supplies between an intensive care unit and other units. Data collection was based on 38 interviews, documents such as floor plans, and observations of logistics activities. Seven BE design principles developed in a previous study, concerned with RP in general but not focused on logistics, were adopted as initial themes for data analysis. Results of the thematic analysis gave rise to a knowledge framework composed of seven design prescriptions and 63 practical examples of BE supportive of RP in hospital internal logistics. The paper discusses how these prescriptions and examples are connected to resilience management. The framework is new in the context of internal hospital logistics and offers guidance to both BE and logistics designers.

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

Hazard Assessment and Remediation Tool for Simulation-Based Healthcare Facility Design Testing

OBJECTIVES

To develop an objective, structured observational tool to enable identification and measurement of hazards in the built environment when applied to audiovisual recordings of simulations by trained raters.

BACKGROUND

Simulation-based facility design testing is increasingly used to optimize safety of healthcare environments, often relying on participant debriefing or direct observation by human factors experts.

METHODS

Hazard categories were defined through participant debriefing and detailed review of pediatric intensive care unit in situ simulation videos. Categories were refined and operational definitions developed through iterative coding and review. Hazard detection was optimized through the use of structured coding protocols and optimized camera angles.

RESULTS

Six hazard categories were defined: (1) slip/trip/fall/injury risk, impaired access to (2) patient or (3) equipment, (4) obstructed path, (5) poor visibility, and (6) infection risk. Analysis of paired and individual coding demonstrated strong overall reliability (0.89 and 0.85, Gwet's AC1). Reliability coefficients for each hazard category were >0.8 for all except obstructed path (0.76) for paired raters. Among individual raters, reliability coefficients were >0.8, except for slip/trip/fall/injury risk (0.68) and impaired access to equipment (0.77).

CONCLUSIONS

Hazard Assessment and Remediation Tool (HART) provides a framework to identify and quantify hazards in the built environment. The tool is highly reliable when applied to direct video review of simulations by either paired raters or trained single clinical raters. Subsequent work will (1) assess the tool's ability to discriminate between rooms with different physical attributes, (2) develop strategies to apply HART to improve facility design, and (3) assess transferability to non-ICU acute care environments.

Anesthesia Workspaces for Safe Medication Practices: Design Guidelines

BACKGROUND

Studies show that workspace for the anesthesia providers is prone to interruptions and distractions. Anesthesia providers experience difficulties while performing critical medication tasks such as medication preparation and administration due to poor ergonomics and configurations of workspace, equipment clutter, and limited space which ultimately may impact patient safety, length of surgery, and cost of care delivery. Therefore, improving design of anesthesia workspace for supporting safe and efficient medication practices is paramount.

OBJECTIVES

The objective of this study was to develop a set of evidence-based design guidelines focusing on design of anesthesia workspace to support safer anesthesia medication tasks in operating rooms (ORs).

METHODS

Data collection was based on literature review, observation, and coding of more than 30 prerecorded videos of outpatient surgical procedures to identify challenges experienced by anesthesia providers while performing medication tasks. Guidelines were then reviewed and validated using short survey.

RESULTS

Findings are summarized into seven evidence-based design guidelines, including (1) locate critical tasks within a primary field of vision, (2) eliminate travel into and through the anesthesia zone (for other staff), (3) identify and demarcate a distinct anesthesia zone with adequate space for the anesthesia provider, (4) optimize the ability to reposition/reconfigure the anesthesia workspace, (5) minimize clutter from equipment, (6) provide adequate and appropriately positioned surfaces for medication preparation and administration, and (7) optimize task and surface lighting.

CONCLUSION

This study finds many areas for improving design of ORs. Improvements of anesthesia work area will call for contribution and cooperation of entire surgical team.

Safety in Health Care: The Impact of Operating Room Design

The science of operating room design has grown over the past 20 years due to the realization that the physical environment influences health care provider performance and patient outcomes. Medical errors occur when the normal workflow in an operating room is disrupted as providers must overcome sub-optimal conditions. All aspects of the physical environment can impact operating room flow. Studying the layout, contents, ergonomics, and environmental parameters of the operating can lead improved work conditions resulting improved patient and provider safety. At the forefront of operating room design science is the use of simulation and the evaluation of new technologies.

Operating room design using agent-based simulation to reduce room obstructions

This study seeks to improve the safety of clinical care provided in operating rooms (OR) by examining how characteristics of both the physical environment and the procedure affect surgical team movement and contacts. We video recorded staff movements during a set of surgical procedures. Then we divided the OR into multiple zones and analyzed the frequency and duration of movement from origin to destination through zones. This data was abstracted into a generalized, agent-based, discrete event simulation model to study how OR size and OR equipment layout affected surgical staff movement and total number of surgical team contacts during a procedure. A full factorial experiment with seven input factors - OR size, OR shape, operating table orientation, circulating nurse (CN) workstation location, team size, number of doors, and procedure type - was conducted. Results were analyzed using multiple linear regression with surgical team contacts as the dependent variable. The OR size, the CN workstation location, and team size significantly affected surgical team contacts. Also, two- and three-way interactions between staff, procedure type, table orientation, and CN workstation location significantly affected contacts. We discuss implications of these findings for OR managers and for future research about designing future ORs.

A Review of Physical and Digital Mock-Up Applications in Healthcare Building Development

Mock-up simulation is a design or human factor research method to help designers identify key design issues and factors of a product or environment. This paper discusses physical mock-up (PMU) and digital mock-up (DMU) applications in healthcare building development through a narrative literature review. The following questions are addressed in this paper: what would the purposes of using PMU or DMU simulations be? At which phase of a hospital design would a PMU or DMU simulation be used? What methods can be used to conduct PMU and DMU simulations? The paper discusses the advantages and disadvantages of these two mock-up methods and highlights the importance of clinical staff’s involvement in mock-up simulations. It gives recommendations for the design practitioners or project managers of healthcare building development recommendations to implement these two mock-up methods in healthcare building development projects.

The impact of design on workflow: a comparative case study of level I trauma rooms

Purpose

This study aims to examine trauma room staff’s perception of factors that influence workflow in trauma care from a physical environment standpoint.

Design/methodology/approach

A semi-structured focus group method was used. Trauma team members, representative of various roles within a team, were recruited from five Level I trauma centers in the USA, through a convenience sampling method. A total of 53 participants were recruited to participate in online focus groups. The Systems Engineering Initiative for Patient Safety model was used to analyze the findings.

Findings

In addition to factors directly related to the physical environment, aspects of people and technology, such as crowding and access to technology, were found to be related to the physical environment. Examples of factors that improve or hinder workflow are layout design, appropriate room size, doors, sink locations, access to resources such as X-ray or blood and access to technology. Seamless and uninterrupted workflow is crucial in achieving efficient and safe care in the time-pressured environments of trauma rooms. To support workflow, the physical environment can offer solutions through effective layout design, thoughtful location of resources and technology and room size.

Originality/value

Trauma rooms are time-pressured and complex environments where seconds matter to save a patient’s life. Ensuring safe and efficient care requires seamless workflow. However, the literature on workflow in trauma rooms is limited.

Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment

OBJECTIVES

Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. The article describes a grant initiative undertaken by the Agency for of Healthcare Research and Quality that brings these disciplines together to test new ideas that could make health care safer.

METHODS

Collectively known as patient safety learning laboratories, grantee teams engage in phase-based activities that parallel a systems engineering process-problem analysis, design, development, implementation, and evaluation-to gain an in-depth understanding of related patient safety problems, generate fresh ideas and rapid prototypes, develop the prototypes, ensure that developed components are implemented as an integrated working system, and evaluate the system in a simulated or clinical setting.

FINDINGS

Obstacles are described that can derail the best of intentions in deploying the systems engineering methodology. Based on feedback received from project teams, lessons learned are emerging that find considerable variation among project teams in deploying the methodology and a longer than anticipated amount of time in bringing team members from different disciplines together where they learn to communicate and function as a team.

CONCLUSIONS

Three narratives are generated in terms of what success might look like. Much is yet to be learned about the limitations and successes of the ongoing learning laboratory initiative, which should be relevant to the broader scale interest in learning health systems.

Proactive Evaluation of an Operating Room Prototype: A Simulation-Based Modeling Approach

OBJECTIVES

There is a pressing need to improve safety and efficiency in the operating room (OR). Postsurgical adverse events, such as surgical site infections and surgical flow disruption, occur at a significant rate in industrial countries where a considerable portion of such complications result in death. The aim of the study was to identify an ideal room design that improves the flow of staff members using risk and safety performance measures.

METHODS

Operating room designs were compared by using computer simulation modeling to analyze traffic flow inside an OR. The study was conducted in two phases. A historical data set was first created based on surgical flow data obtained from 23 video observations of actual surgical procedures. A detailed simulation-based model was then developed.

RESULTS

As room size increases, staff members have more available space to maneuver in the room, resulting in more distance walked but far fewer undesirable contacts. An angled table orientation is preferred with the circulating nurse workstation at the foot of the OR table, as it provides more space for staff to move across the room without increasing the number of contacts. Furthermore, when the nurse workstation is near the wall, staff members experience fewer undesirable contacts.

CONCLUSIONS

Simulation modeling was used to assess the impact of OR layout alternatives on three performance metrics, and the medium-sized OR prototype performs well across the metrics. Future research will consider the relative influence of several factors on traffic-based safety and efficiency performance metrics, resulting in a more predictive simulation design model.

The Role of the Physical Environment in Shaping Interruptions and Disruptions in Complex Health Care Settings: A Scoping Review

Interruptions and disruptions in complex healthcare environments, such as trauma rooms, can lead to compromised workflow and safety issues due to the physical environment's characteristics. This scoping review investigated the impact of the physical environment on interruptions and disruptions and the associated outcomes in complex environments, as they relate to the components of the Systems Engineering Initiative for Patient Safety. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to conduct the scoping review. CINAHL, Web of Science, and PubMed databases were searched. After removing duplicates and eligibility screening, quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Of 1,158 articles found, 20 were selected. Poor layout configurations, tripping hazards, and technology integration were common examples. More research must be conducted to unveil the impact of the physical environment on interruptions and disruptions.

Using Virtual Reality (VR) Mock-Ups for Evidence-Based Healthcare Facility Design Decisions

(1) Background: There are many complexities and trade-offs that design teams consider when designing or renovating a built environment for healthcare. Virtual reality (VR) mock-ups can allow design teams to evaluate the planned design. This study aimed to examine the overall value of using VR mock-ups to conduct a simulation-based mock-up evaluation. (2) Methods: Data collected from scenario enactments within a VR mock-up was compared to data collected from an existing medication room with the same design to assess predictive validity. Outcomes regarding quality and patient safety were also examined as a result of design modifications to the VR mock-up which were identified through a post-occupancy evaluation (POE) of the existing medication room. Survey data from participants, hospital design stakeholders, and POE recommendation recipients captured perceptions regarding the evaluation process. Specifically, this included perceptions regarding mock-up and scenario realism as well as utility of the evaluation process. (3) Results: Evidence-based data collected using the VR mock-up accurately assessed workflow (link analysis), bumps, impediments, interruptions, and task completion times. Collecting data pertaining to selection errors and equipment placement were identified after procuring the VR software and therefore the accuracy of these measures was not assessed. Searching behaviours were not possible to capture using the VR software. A 506% return on investment was achieved through the VR mock-up evaluations. (4) Conclusion: Organizations should consider what evaluation objectives are planned and how they will be measured for a mock-up evaluation to determine if VR is appropriate.

Comparing User Perceptions of Surgical Environments: Simulations in a High-Fidelity Physical Mock-Up Versus a Postoccupancy Evaluation

OBJECTIVE

The purpose of this study was to compare perceptions and behaviors of end users participating in simulations in a high-fidelity physical mock-up of an operating room (OR) prototype with the perceptions and behaviors of end users in the built out ORs postoccupancy.

BACKGROUND

Simulation-based evaluations of high-fidelity physical mock-ups of proposed layouts are increasingly being conducted during the facility design process to understand impacts on workflow and potential adverse patient safety outcomes. Nevertheless, it is unclear to what extent user experiences in these simulated healthcare spaces are similar to those in built and occupied healthcare environments.

METHODS

Using interviews, surveys, and observations, this study compared user evaluations in a high-fidelity physical mock-up of an OR with user evaluations of the built and occupied OR postoccupancy. Workflow disruptions were also analyzed using video recordings for a simulated pediatric surgery and five pediatric surgeries in the actual OR.

RESULTS

This study found that user perceptions and behavior in the two types of environments were mostly similar with regard to perceived support for the location of surgeon workstation, perceived space and task performance, perceived access to storage locations, boom setup, and OR cleanability. Participant's ratings differed for supportiveness of the mobile Circulating Nurse (CN) workstation, maneuvering booms, and environmental disruptions.

CONCLUSION

Simulation-based evaluations are extremely beneficial during the design process and can provide valuable input to design teams as well as clinical teams about workflow and safety issues that allow design issues to be addressed before construction.

Impact of Surgical Table Orientation on Flow Disruptions and Movement Patterns during Pediatric Outpatient Surgeries

(1) Background: The surgical table within a typical ambulatory surgery operating room is frequently rotated and placed in different orientations to facilitate surgery or in response to surgeon preferences. However, different surgical table orientations can impact access to different work zones, areas and equipment in the OR, potentially impacting workflow of surgical team members and creating patient safety risks; (2) Methods: This quantitative observational study used a convenience sample of 38 video recordings of the intraoperative phase of pediatric outpatient surgeries to study the impacts of surgical table orientation on flow disruptions (FDs), number of contacts between team members and distance traveled; (3) Results: This study found that the orientation of the surgical table significantly influenced staff workflow and movement in the OR with an angled surgical table orientation being least disruptive to surgical work. The anesthesia provider, scrub nurse and circulating nurse experienced more FDs compared to the surgeon; (4) Conclusions: The orientation of the surgical table matters, and clinicians and architects must consider different design and operational strategies to support optimal table orientation in the OR.

Pediatric Intensive Care Unit (PICU) Patient Room Design: Identifying Safety Risks in Mirrored Rooms Through a Graphical Systems Analysis

OBJECTIVE

The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach.

BACKGROUND

The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care.

METHODS

An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert.

RESULTS

Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations.

CONCLUSION

Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.

Operating room architecture is not a risk factor for surgical site infections

Surgical site infection (SSI) may cause a substantial burden for patients and healthcare systems. A potential risk of different architectures of the operating room for SSI is yet unknown and was subject of this study. This observational cohort study was performed in a university hospital and evaluated patients, who underwent a broad spectrum of orthopedic surgeries in 2016 (open-plan operating room architecture) versus (vs) 2017 (closed-plan operating room architecture). Patients, who underwent surgery in the transition time period from the open-plan to the closed-plan operating room architecture and those, who were treated e.g. for osteomyelitis as index procedure were excluded. The primary outcome was revision surgery for early SSI within 30 (superficial) or 90 (deep or organ/space) days of surgery. Age, gender, American society of anesthesiologists (ASA) classification, and the body mass index (BMI) were considered as potential interacting factors in a logistic regression analysis. The incidence of revisions for SSI was 0.6 percent (%) (n = 45) in the 7'740 included surgical cases (mean age of 52 (standard deviation (SD) 19) years; n = 3'835 (50%) females). There was no difference in incidences of revision for SSI in the open- vs closed-plan operating room architecture (0.5% vs 0.7%; adjusted odds ratio (OR) = 1.34 (95% confidence interval (CI) 0.72-2.49, P = 0.35)). Age and gender were not a risk factor for revision for SSI. However, ASA classification and BMI were identified as risk factors for the incidence of revision for SSI (OR = 1.92 (95% CI 1.16- 3.18, P = 0.01) and OR = 1.05 (95% CI 1.00-1.11, P = 0.05)). The overall incidence of revisions for early SSI after a broad spectrum of orthopedic surgeries was relatively low (0.6%) and independent from the operating room architecture. An increase in ASA classification and possibly BMI, however, were identified as independent risk factors for revision for SSI.

Transfer of ergonomics knowledge from participatory simulation events into hospital design projects

BACKGROUND

Participatory simulation (PS) is a method that can be used to integrate ergonomics and safety into workplace design projects. Previous studies have mainly focused on tools and methods for the simulation activities. The subsequent process of transferring and integrating the simulation outcomes into the design of workplaces is poorly understood.

OBJECTIVE

This study sets out to study the role of actors and objects in the transfer of ergonomics knowledge generated in PS events and in the integration of this knowledge into a design project. The study identifies factors that influence what part of the simulation outcomes are integrated.

METHODS

The empirical context of the study was six PS events that were part of a hospital design project. The events were investigated based on knowledge transfer theory, observations, interviews and document studies.

RESULTS

Actors and objects with abilities of transferring ergonomics knowledge from the PS events to the hospital design project were identified. The study indicated that persons producing the objects functioned as a filter, meaning that not all ergonomics knowledge was transferred from the PS events. The main influencing factors on the integration were: predetermined building dimensions and room interdependency.

CONCLUSIONS

Four recommendations were proposed for ergonomists and safety professionals when planning PS events.

Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff well-being and organizational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees-sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent coronavirus disease of 2019 (COVID-19) experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.

An empirical regression model toward optimized ergonomic conditions for monitoring room operators using RSM

Purpose

This study aims to provide an ergonomic design of the monitoring room that has resulted in safe, functional and comfortable environment for the operators, which may lead to improve the efficiency. Currently, uses of closed‐circuit televisions to monitor the critical environments are widely applicable. The information is continuously transferred and analyzed through a center called monitoring room.

Design/methodology/approach

Here, through creating a systematic analysis, a series of experiments was performed initially to evaluate and then optimize the parameters such as illumination, visual angle, operator-screen distance, number of scenes display in a single screen, workstation height, screen dimension and monitoring time that may affect the visual skill of the operators. Taguchi orthogonal array was used to analyze the significance of parameters on operator’s response time to a threat. The five parameters were distinguished as significant. Later response surface methodology was utilized to optimize the parameters.

Findings

Quadratic empirical model developed for the response time exposes the optimum response time was achievable at illumination of 500 lux, visual angle of 13°, operator-screen distance of 60 cm, three scenes, workstation height of 120 cm, screen dimension of 34” and monitoring time of 15 min. This shortened the response time by 28 per cent. The adequacy of the fitted model was successfully verified using the confirmation test with α = 95 per cent.

Originality/value

The novelty of this work lies in the application of a systematic statistical analysis, which enables considering the interaction among the noise parameters and controllable one simultaneously. Furthermore, the obtained regression model can widely be used for adjusting the parameters accordingly based on various anthropometric data.

Surgical workflow simulation for the design and assessment of operating room setups in orthopedic surgery

BACKGROUND

The design and internal layout of modern operating rooms (OR) are influencing the surgical team's collaboration and communication, ergonomics, as well as intraoperative hygiene substantially. Yet, there is no objective method for the assessment and design of operating room setups for different surgical disciplines and intervention types available. The aim of this work is to establish an improved OR setup for common procedures in arthroplasty.

METHODS

With the help of computer simulation, a method for the design and assessment of enhanced OR setups was developed. New OR setups were designed, analyzed in a computer simulation environment and evaluated in the actual intraoperative setting. Thereby, a 3D graphical simulation representation enabled the strong involvement of clinical stakeholders in all phases of the design and decision-making process of the new setup alternatives.

RESULTS

The implementation of improved OR setups reduces the instrument handover time between the surgeon and the scrub nurse, the travel paths of the OR team as well as shortens the procedure duration. Additionally, the ergonomics of the OR staff were improved.

CONCLUSION

The developed simulation method was evaluated in the actual intraoperative setting and proved its benefit for the design and optimization of OR setups for different surgical intervention types. As a clinical result, enhanced setups for total knee arthroplasty and total hip arthroplasty surgeries were established in daily clinical routine and the OR efficiency was improved.

The Fit Between Spatial Configuration and Idealized Flows: Mapping Flows in Surgical Facilities as Part of Case Study Visits

PURPOSE

This study proposes a flow mapping approach for surgical facilities that can be implemented by design teams as a component of case study tours.

BACKGROUND

The provision of healthcare services involves simultaneous and closely coupled flows of people, objects, and information, and the efficiency of these flows is influenced by the spatial configuration of the buildings where these services are housed. Many architecture firms conduct case study tours to inform their design process. However, these tours often lack a structured way of documenting different flows and interpreting observations. A structured approach is needed during the design process to understand the impact of spatial configuration on healthcare flows.

METHOD

Site tours were conducted at four surgery centers to develop and test an evidence-based flow mapping approach. Idealized flows within surgical facilities were first identified from the literature, followed by the development of a data collection tool aimed at documenting these flows in each case study through a pre-assessment questionnaire, a physical assessment, and interviews with staff.

RESULTS

The flow mapping tool kit was effective in allowing the design team to systematically understand the physical configuration of surgical flows across case studies. The tool also allowed the team to identify spatial configuration characteristics acting as barriers and facilitators to idealized flows.

CONCLUSIONS

The flow mapping approach was able to provide structure for conducting these short tours more effectively via observations and staff inquiry, enabling design teams to draw more meaningful conclusions from case study tours and conduct comparisons between healthcare facilities visited.

Designing for Patient Safety and Efficiency: Simulation-Based Hospital Design Testing

OBJECTIVE

In the schematic design phase of a new freestanding children's hospital, Simulation-based Hospital Design Testing (SbHDT) was used to evaluate the proposed design of 11 clinical areas. The purpose of this article is to describe the SbHDT process and how it can help identify and mitigate safety concerns during the facility design process.

BACKGROUND

In the design of new healthcare facilities, the ability to mitigate risk in the preconstruction period is imperative. SbHDT in a full-scale cardboard mock-up can be used to proactively test the complex interface between people and the built environment.

METHOD

This study was a prospective investigation of SbHDT in the schematic design planning phase for a 400-bed freestanding children's hospital where frontline staff simulated episodes of care. Latent conditions related to design were identified through structured debriefing. Failure mode and effect analysis was used to categorize and prioritize simulation findings and was used by the architect team to inform design solutions. A second round of testing was conducted in order to validate design changes.

RESULTS

A statistically significant reduction in criticality scores between Round 1 (n = 201, median = 16.14, SD = 5.8) and Round 2 (n = 201, median score of 7.68, SD = 5.26, p < .001) was identified. Bivariate analysis also demonstrated a statistically significant reduction in very high/high criticality scores between Round 1 and Round 2.

CONCLUSIONS

SbHDT in the schematic phase of design planning was effective in mitigating risk related to design prototypes through effective identification of latent conditions and validation of design changes.

Determining fidelity of mixed prototypes: Effect of media and physical interaction

Mixed prototyping, combining virtual and physical prototypes, is an emerging method used to aid in usability testing. This study aims to determine when to use a mixed prototype and how to choose its fidelity to validate the usability testing results and reduce the prototyping cost. A 2×2 between-subject experiment was designed to investigate the effects of the media (head-mounted display versus computer monitor) and physical interaction (using a tangible mock-up or not) on the usability evaluation results and other subjective measures. The experiment results showed that, when aesthetic and functional features are controlled, the non-functional mock-up facilitates users in finding problems regarding physical interaction and ergonomics. Media with high immersion positively influenced the users' subjective ratings. Based on the findings of this study, guidelines on how to choose the fidelity of the prototype during different stages of a usability test are suggested to help product developers find a cost-efficient way to conduct usability tests.

Simulation-based clinical systems testing for healthcare spaces: from intake through implementation

Healthcare systems are urged to build facilities that support safe and efficient delivery of care. Literature demonstrates that the built environment impacts patient safety. Design decisions made early in the planning process may introduce flaws into the system, known as latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) has successfully been incorporated in the post-construction evaluation process in order to identify LSTs prior to patient exposure and promote preparedness, easing the transition into newly built facilities. As the application of simulation in healthcare extends into the realm of process and systems testing, there is a need for a standardized approach by which to conduct SbCST in order to effectively evaluate newly built healthcare facilities. This paper describes a systemic approach by which to conduct SbCST and provides documentation and evaluation tools in order to develop, implement, and evaluate a newly built environment to identify LSTs and system inefficiencies prior to patient exposure.

Evaluation of a Mental and Behavioral Health Patient Room Mockup at a VA Facility

OBJECTIVE

The primary goal of this research was to evaluate a physical full-scale, high-fidelity mockup of a mental and behavioral health (MBH) inpatient room and bathroom.

BACKGROUND

There is minimal research on design for MBH and no published research using mockups to evaluate a MBH design proposal. To address this gap, an interdisciplinary team developed an ideal Patient-Centered MBH Patient Room, which was built as a mockup at a Veterans Administration (VA) facility and evaluated by patients and staff in situ.

METHOD

The mock-up was evaluated using a structured mixed methods process that incorporates feedback using Feedback Forms and facilitated Listening Sessions. Our two primary hypotheses were that the design, as represented by the mock-up, would be positively evaluated and that there would be a difference between staff and patient perceptions, with patients rating the design higher than staff.

RESULTS

Quantitative analysis confirmed our hypotheses, revealing an overall positive response, with a difference between patients and staff. Contrary to hypothesis, staff consistently rated the design higher than patients. Qualitative analysis found mixed reception of the design and three primary themes: safety, homeyness/deinstitutionalization, and positive distraction/nature.

CONCLUSIONS

Physical mock-ups may be an effective tool for evaluation of a proposed design; however, staff perceptions of the environment may differ from those of patients. One drawback of using a physical high-fidelity mock-up is the expectation that the mock-up perfectly represents the proposed design. With this project, even small unfinished details were distracting to the participants and may have negatively affected the evaluation.

Prevent Safety Threats in New Construction through Integration of Simulation and FMEA

Introduction

The built environment may impact safety and decisions made during the design phases can have unintended downstream effects that lead to patient harm. These flaws within the system are latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) provides a clinical context to examine the environment for safety threats postconstruction. Integration of Failure Mode Effect Analysis (FMEA) with SbCST provides a framework to identify, categorize, and prioritize LSTs before patient exposure.

Methods

We implemented SbCST in a newly constructed pediatric subspecialty outpatient center before opening. We used in-situ simulations to evaluate both routine and high-risk clinical scenarios pertinent to each clinical area. FMEA was used as a methodology to assign risk, prioritize, and categorize LSTs identified during the simulation.

Results

Over 3 months, we conducted 31 simulated scenarios for 15 distinct subspecialty clinics involving 150 participants and 151 observers. We identified a total of 334 LSTs from 15 distinct clinics. LSTs were further classified into process/workflow, facility, resource, or clinical performance issues.

Conclusions

Integration of SbCST and FMEA risk assessment is effective in evaluating a new space for safety threats, workflow, and process inefficiencies in the postconstruction environment, providing a framework for prioritizing issues with the greatest risk for harm.

Simulation-Based Mock-Up Evaluation of a Universal Operating Room

Designing or renovating a physical environment for healthcare is a complex process and is critical for both the staff and the patients who rely on the environment to support and facilitate patient care. Conducting a simulation-based mock-up evaluation as part of the design process can enhance patient safety, staff efficiency, as well as user experience, and can yield financial returns. A large urban tertiary care center located in Vancouver, Canada followed a framework to evaluate the proposed design template for 28 universal operating rooms (ORs) included within the OR Renewal Project scope. Simulation scenarios were enacted by nursing staff, surgeons, anesthesiologists, residents, radiology techs, and anesthesia assistants. Video and debriefing data were used to conduct link analyses, as well as analyses of observed behaviors including congestions and bumps to generate recommendations for evidence-based design changes that were presented to the project team. Recommendations incorporated into the design included relocating doors, booms, equipment, and supplies, as well as reconfigurations to workstations. These recommendations were also incorporated into the mock-up and retested to iteratively develop and evaluate the design. Findings suggest that incorporating the recommended design changes resulted in better room utilization, decreased congestion, and enhanced access to equipment.

Using Virtual Reality to Compare Design Alternatives Using Subjective and Objective Evaluation Methods

OBJECTIVE

This study sought to develop a method that supports a more evidence-based approach to evaluating multiple design options in virtual reality (VR), combining subjective insights gathered using traditional approaches and objective feedback gathered using the VR platform. Additionally, this study sought to understand how objective data garnered from the VR platform could be used to compliment traditional evaluation strategies.

BACKGROUND

VR can be a viable research platform for supporting evidence-based design practices. Prior studies have predominately utilized experiential user feedback. While able to provide valuable subjective insights, these approaches are less effective in making objective comparisons between multiple designs alternatives.

METHOD

A repeated measures study was conducted with nursing faculty. User feedback was captured through surveys, interviews, and the VR platform.

RESULTS

The survey, interview, and the objective VR data converged in terms of identifying the highest performing design option. Survey data showed that Room 2 performed best in terms of perceived physical access to supplies, unobstructed movement, and availability of space to accommodate additional equipment. VR data showed that participants in Room 2 had significantly higher visibility to both patient and care partners throughout their simulated interaction.

CONCLUSION

Simulation-based evaluations in VR that use a combination of users' subjective insights and objective data obtained from VR can be an effective tool for helping designers evaluate multiple design options. The use of scenario-based simulations provided a structured and clinically relevant approach to comparing three preoperative rooms, supporting a more robust assessment of users' physical response to a simulated healthcare environment.

Mock-Ups: Using Experiential Simulation Models in the Healthcare Design Process

PURPOSE

The purpose of this article was to explore how different types of mock-ups are being used in the healthcare design process and present a methodology framework for the process.

BACKGROUND

Historically, physical mock-ups have been used in healthcare design primarily to test construction techniques. Although this historic use of mock-ups assisted the design team in decision-making, newer forms of mock-ups have evolved that expand the input provided into decision-making. These newer techniques, rapid prototyping, early build-out, virtual reality, and enhancements to the traditional physical mock-up focus more on challenging the functionality of the space, testing new operational concepts, and increasing user input.

METHOD

This methodology article utilized five case studies in which different types and combinations of mock-ups were used in the design process and then, the methodology compares the realism, immersion, and testability of each mock-up technique.

RESULTS

For each mock-up type, the case studies described the purpose of the technique, the advantages and disadvantages, the most appropriate phase for its use in the design process, the estimated cost, and the process logistics. These components are compared to assist in developing a methodology for a variety of design situations.

CONCLUSIONS

The findings related to different mock-up techniques are a valuable tool for healthcare design teams to use in selecting the most appropriate mock-up technique and the proposed methodology will assist in executing the mock-up process.

A method for quantifying key components of the opening process for opening pouch-style packages containing medical devices

Healthcare-associated infections are a serious worldwide health concern. Although contaminated medical devices are an avenue for infection, little research has evaluated the techniques used to open sterile packages. The goal of this study was to develop a method to quantify aspects of the package opening process in accordance with opening guidelines and then to demonstrate this methodology through a small sample of clinicians opening two sizes of pouch-style packages. Using motion capture techniques, a method was designed to quantify 11 parameters associated with the opening process. The method was then tested with nine healthcare professionals. Results indicated that all participants crossed the sterile field when opening packages. When opening large packages, participants spent significantly more time over the simulated sterile field and there was a trend towards more manipulations as compared to opening smaller packages. This methodology can be used to quantify the opening process, compare opening practices, and for assessment during the learning process.

Comparing the Effectiveness of Four Different Design Media in Communicating Desired Performance Outcomes With Clinical End Users

OBJECTIVE

The purpose of this study was to compare the effectiveness of four different design communication media in helping clinical end users understand spatial and functional information and in supporting their ability to provide design feedback.

BACKGROUND

It is critical to involve clinical end users early in the design process to test design solutions and ensure the design of a new healthcare facility supports their ability to deliver high-quality care. Traditional architectural design communication media such as floor plans and perspectives can be challenging for clinical design team members to understand. Physical and virtual mock-ups are becoming more popular as design communication media. However, nominal evidence exists comparing the effectiveness of different design media in supporting clinical end-user engagement and contribution during the design process.

METHOD

An exploratory, qualitative study was conducted with clinical end users to evaluate the effectiveness of four different media commonly used in design communication.

RESULTS

Traditional architectural representations convey limited useful information to clinical end users, impacting the amount and type of feedback they can provide. More immersive media, such as physical and virtual mock-ups, support an increasingly holistic understanding of proposed design solutions, inciting more design solutions that range from the inclusion and exclusion of design features to location, position, and functionality of those features.

CONCLUSIONS

When used in combination, each media can contribute to eliciting clinical end-user feedback at varying scales. The overall preference and higher effectiveness in eliciting design feedback from clinical end users highlights the importance of physical mock-up in communicating healthcare design solutions.