Exploring the impact of the physical environment on patient outcomes in ambulatory care settings

Designing Worthy Waiting Spaces: A Cross-Cultural Study of Waiting Room Features and Their Impact on Women's Affective States

OBJECTIVE

This study examines the impact of ambulatory waiting room characteristics on patients' emotional states and investigates whether these states are universally experienced or influenced by social and cultural factors among women aged 18-35 from the three largest demographic groups in the United States: Black, Hispanic/Latina, and White.

BACKGROUND

Patients typically spend more time waiting for routine medical appointments than receiving care, and evidence suggests that waiting can reinforces power dynamics that benefit privileged groups, leading to different experiences for minority women seeking preventative care. Still, literature addressing the impact of waiting areas is largely limited to universal measures, and little is known about how different ethnic/race groups respond to waiting spaces.

METHODS

This inquiry used a questionnaire assessing 15 waiting room characteristics and testing four variables (furniture arrangement, room-scale, color saturation, and quantity of positive distractions) in a 2 × 3 quasiexperiment using a fractional randomized block design with 24 waiting room images.

FINDINGS

Responses from 1,114 participants revealed mutual preferences for sociopetal seating, positive distractions, neutral colors, and welcoming and calming environments. Yet, Black participants indicated significantly greater importance in seeing ethnically/racially similar patients and healthcare providers and strategies that promote transparency, including image-based provider directories and views into the clinic.

CONCLUSION

By investigating the impact of the waiting room environment on patient affect and comparing perceptions across three demographic groups of women, this study offers insights into potential strategies for improving access to preventative care services by creating more welcoming ambulatory care waiting environments.

Agreement between individual and neighborhood income measures in patients with colorectal cancer in Canada

INTRODUCTION

With increasing interest in income-related differences in cancer outcomes, accurate measurement of income is imperative. Misclassification of income can result in wrong conclusions as to the presence of income inequalities. We determined misclassification between individual- and neighborhood-level income and their association with overall survival among colorectal cancer (CRC) patients.

METHODS

The Canadian Census Health and Environment Cohorts were used to identify CRC patients diagnosed from 1992 to 2017. We used neighborhood income quintiles from Statistics Canada and created individual income quintiles from the same data sources to be as similar as possible. Agreement between individual and neighborhood income quintiles was measured using cross-tabulations and weighted kappa statistics. Cox proportional hazards and Lin semiparametric hazards models were used to determine the effects of individual and neighborhood income independently and jointly on survival. Analyses were also stratified by rural residence.

RESULTS

A total of 103 530 CRC patients were included in the cohort. There was poor agreement between individual and neighborhood income with only 17% of respondents assigned to the same quintile (weighted kappa = 0.18). Individual income had a greater effect on relative and additive survival than neighborhood income when modeled separately. The interaction between individual and neighborhood income demonstrated that the most at risk for poor survival were those in the lowest individual and neighborhood income quintiles. Misclassification was more likely to occur for patients residing in rural areas.

CONCLUSION

Cancer researchers should avoid using neighborhood income as a proxy for individual income, especially among patients with cancers with demonstrated inequalities by income.

Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation

OBJECTIVE

To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication.

BACKGROUND

Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes.

METHODS

This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis.

RESULTS

Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients.

CONCLUSIONS

Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

Influence of Environmental Design on Team Interactions Across Three Family Medicine Clinics: Perceptions of Communication, Efficiency, and Privacy

OBJECTIVE

In this study, we explored how two different primary care clinic physical layouts (onstage/offstage and pod-based [PB] designs) influenced pre- and postvisit team experiences and perceptions.

BACKGROUND

Protocols encourage healthcare team communication before and after primary care visits to support better patient care. Physical clinic environments may influence these behaviors, but limited research has been performed.

METHOD

We conducted observations, three interviews with clinic managers, and six focus groups with 21 providers and staff at three family medicine teaching clinics. Observational data were captured through field notes and spaghetti diagrams. Interviews and focus groups were recorded, transcribed, and analyzed using a grounded theory-based approach to understand how aspects of the clinic environment affected communication, efficiency, and privacy.

RESULTS

Variations in communication styles and trade-offs between patient contact and privacy emerged as differences. In the onstage/offstage design, colocated teams had increased verbal communication but perceived being isolated from other clinic teams. In contrast, teams in PB clinics communicated with other clinic teams but had more informal patient contact within care-team stations that imposed privacy risk.

CONCLUSIONS

Primary care clinic design appears to alter provider-team and patient-provider communication and flow. Organizations should consider aligning environmental design with desired interaction patterns when building new primary care clinics.

The impact of contextual factors on nursing outcomes and the role of placebo/nocebo effects: a discussion paper

INTRODUCTION

Placebo and nocebo effects represent one of the most fascinating topics in the health care field.

OBJECTIVES

the aims of this discussion paper were (1) to briefly introduce the placebo and nocebo effects, (2) to elucidate the contextual factors able to trigger placebo and nocebo effects in the nursing field, and (3) to debate the impact of contextual factors on nursing education, practice, organisation, and research.

METHODS

a narrative review was conducted based on the available evidence.

RESULTS

Placebo responses (from Latin "I shall please") are a beneficial outcome(s) triggered by a positive context. The opposite are the nocebo effects (from Latin "I shall harm"), which indicates an undesirable outcome(s) caused by a negative context. Both are complex and distinct psychoneurobiological phenomena in which behavioural and neurophysiological changes arise subsequent to an interaction between the patient and the health care context.

CONCLUSION

Placebo and nocebo concepts have been recently introduced in the nursing discipline, generating a wide debate on ethical issues; however, the impact on nursing education, clinical practice, nursing administration, and research regarding contextual factors triggering nocebo and placebo effects has not been debated to date.

Facility Layout Planning with SHELL and Fuzzy AHP Method Based on Human Reliability for Operating Theatre

A well-design facility layout planning refers to the reduction of the operation cost in the manufacturing and service industry. This work consists of reliability analysis of facility layout for an operating theatre; it aims at proposing a new evaluation approach, which integrated the fuzzy analytic hierarchy process and human reliability tool, for optimization of facility layout design with safety and human factors in an operating theatre. Firstly, the systematic layout planning is used to design the layout schemes on the basis of field investigations. Then, the criteria system is proposed based on human reliability analysis from four perspectives: software, hardware, environment, and liveware. Finally, the fuzzy analytic hierarchy process, a fuzzy extension of the multicriteria decision-making technique analytic hierarchy process, is used to compare these layout schemes based on the criteria system. The results that are obtained reveal interesting properties of facility layout planning in hospitals. It reveals that decision in selecting a suitable layout must meet not only the strategies and goals of the system but also meet the safety, security, and reliability of the system.

Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design

This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000–>5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future.

Conceptualizing Health Promotion in Relation to Outpatient Healthcare Building Design: A Scoping Review

OBJECTIVE:

This review explored different conceptualizations of health promotion in the context of, and in relation to, outpatient building design.

BACKGROUND:

Today's healthcare organizations are implementing holistic healthcare approaches such as health promotion, while simultaneously increasing their outpatient services. These health promotion approaches, focused on empowering people to take control of their health, are expected to have implications for the outpatient healthcare building design. Yet there is limited knowledge what these may be. A review of the literature on the current state of the art is thus needed to enable and support dialog on future healthcare building design.

METHOD:

A scoping review of 4,506 papers, collected from four databases and three scientific journals in 2015, resulted in 14 papers relating health promotion to building design and outpatient healthcare. From the subsequent content analysis, multiple common themes and subthemes emerged.

RESULTS:

The review reveals diverse range of health promotion interpretations, three health promotion perspectives (health behavior, health equity, and sense of coherence), associated design approaches, design objectives, health-related outcomes, building features, and solutions.

CONCLUSIONS:

While diverse health promotion perspectives might merely represent variations in focus, these differences become problematic when relating to building design. To support further dialogs on development of health promotion in, and in relation to, the build environment, there is a need to strengthen the health promotion vocabulary. Further research is needed to compare different design approaches and how these can be combined to minimize contradicting implications for building design.

Setting the Stage: A Comparative Analysis of an Onstage/Offstage and a Linear Clinic Modules

Objective:

The purpose of this study was to understand how two different ambulatory design modules—traditional and onstage/offstage—impact operational efficiency, patient throughput, staff collaboration, and patient privacy.

Background:

Delivery of healthcare is greatly shifting to ambulatory settings because of rapid advancement of medicine and technology, resulting in more day procedures and follow-up care occurring outside of hospitals. It is anticipated that outpatient services will grow roughly 15–23% within the next 10 years (Sg2, 2014). Nonetheless, there is limited research that evaluates how the built environment impacts care delivery and patient outcomes.

Method:

This is a cross-sectional, comparative study consisted of a mixed-method approach that included shadowing clinic staff and observing and surveying patients. The linear module had shared corridors and publicly exposed workstations, whereas the onstage/offstage module separates patient/visitors from staff with dedicated patient corridors leading to exam rooms (onstage) and enclosed staff work cores (offstage). Roughly 35 hr of clinic staff shadowing and 55 hr of patient observations occurred. A total of 269 questionnaires were completed by patients/visitors.

Results:

The results demonstrate that the onstage/offstage module significantly improved staff workflow, reduced travel distances, increased communication in private areas, and significantly reduced patient throughput and wait times. However, patients’ perception of privacy did not change among the two modules.

Conclusion:

Compared to the linear module, this study provides evidence that the onstage/offstage module could have helped to optimize operational efficiencies, staff workflow, and patient throughput.

Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care

PURPOSE

This study sought to describe features of the physical space in which practices integrating primary care and behavioral health care work and to identify the arrangements that enable integration of care.

METHODS

We conducted an observational study of 19 diverse practices located across the United States. Practice-level data included field notes from 2-4-day site visits, transcripts from semistructured interviews with clinicians and clinical staff, online implementation diary posts, and facility photographs. A multidisciplinary team used a 4-stage, systematic approach to analyze data and identify how physical layout enabled the work of integrated care teams.

RESULTS

Two dominant spatial layouts emerged across practices: type-1 layouts were characterized by having primary care clinicians (PCCs) and behavioral health clinicians (BHCs) located in separate work areas, and type-2 layouts had BHCs and PCCs sharing work space. We describe these layouts and the influence they have on situational awareness, interprofessional "bumpability," and opportunities for on-the-fly communication. We observed BHCs and PCCs engaging in more face-to-face methods for coordinating integrated care for patients in type 2 layouts (41.5% of observed encounters vs 11.7%; P < .05). We show that practices needed to strike a balance between professional proximity and private work areas to accomplish job tasks. Private workspace was needed for focused work, to see patients, and for consults between clinicians and clinical staff. We describe the ways practices modified and built new space and provide 2 recommended layouts for practices integrating care based on study findings.

CONCLUSION

Physical layout and positioning of professionals' workspace is an important consideration in practices implementing integrated care. Clinicians, researchers, and health-care administrators are encouraged to consider the role of professional proximity and private working space when creating new facilities or redesigning existing space to foster delivery of integrated behavioral health and primary care.

Demonstrating the Effect of the Built Environment on Staff Health-Related Quality of Life in Ambulatory Care Environments

OBJECTIVE

To determine the impact of the built environment on staff health-related quality of life (HRQoL) in a federally qualified health center (FQHC).

BACKGROUND

Staff within FQHCs face many challenges that can significantly impact their HRQoL. Design features directed toward reducing stress have been shown to improve staff health outcomes in acute care environments. However, minimal literature exists linking design features to health outcomes within FQHCs.

METHOD

A cross-sectional, observational study was conducted involving three FQHCs that contain varying levels of enhancements to their interior features. A total of 75 staff across the sites participated in the indoor environmental quality (IEQ) survey, measuring satisfaction and perceived productivity. Measurements for staff HRQoL were captured using the quality of well-being (QWB) scale, which was administered to 10 staff at each site. Standard regression diagnostics were used to examine fit and find influential observations.

RESULTS

QWB scores were normally distributed, and a dose-response relationship was found between QWB scores and level of enhancements. As the categories of satisfaction and perceived productivity increased, the average QWB score increased. Regression models showed overall statistical significance and predicted between a quarter to a half of the change in QWB scores.

CONCLUSIONS

This pilot study suggests that the more enhancements included in the interior features of a FQHC, the greater the returns to staff HRQoL. Findings also suggest that staff with a lower QWB appreciate enhancements more. Design strategies associated with improved staff well-being should be evaluated in terms of the amount of HRQoL they contribute.