Flexibility during the COVID-19 Pandemic Response: Healthcare Facility Assessment Tools for Resilient Evaluation

Benchmarking Relevance for Hospital Design and Planning: An International Web-Based Survey

OBJECTIVE

The study aims to investigate what design practitioners and healthcare facility managers deem as important benchmarking metrics worldwide, investigating country differences in benchmarking usage and which metrics are prioritized.

BACKGROUND

Benchmarking is a regular practice in the healthcare sector, both for clinical and managerial aspects to compare, measure, and improve standardized processes. However, limited knowledge is available about benchmarking procedures in hospital planning, design, and construction.

METHODS

A web-based survey was designed, revised, and pilot-tested in five countries; it was adjusted according to local experts' suggestions and submitted globally via SoSci multilingual platform to persons involved in hospital design, research, construction, and facility management. It was composed of closed questions on 5-point Likert-type scale ranking frequency or importance and open-ended questions divided into six sections. Two hundred and eighty full responses have been collected. Statistical analysis was performed via PowerBI and R-Studio, while qualitative analysis was performed via MAXQDA.

RESULTS

The findings reported allow for both specific insights per each country or category as well as enabling general considerations of a practice that is becoming always more international with 30%-50% of respondents working in the international context. The evaluation of the survey highlights the most important benchmarks, among others. For example, for respondents from the top five countries (Sweden, Spain, Germany, Italy, and the United States), the most important metric for benchmark comparability is whether the project was new construction, new construction attached to an existing hospital, or interior renovation. Construction date, client type (public vs. private), and country of location were also generally rated as the most important metrics by respondents. Other metrics that were consistently rated as important globally included inpatient unit layout, walking distances, number of floors, and whether all patient rooms are private. Space-related metrics are considered very important elements in the design and planning of healthcare facilities worldwide. Regarding cost-related metrics, all countries consider the ratio construction cost per building gross area as the most important.

CONCLUSIONS

Benchmarking emerges as a relevant tool for hospital design and planning as it can support efficiency, standardization, and confidence; currently, benchmarking is still underutilized due to the challenge of international comparison, access to data outside each specific company, and variation design metrics nationally. Benchmarking strategies should be further investigated to support knowledge exchange and to ensure reliable and comparable information globally.

Developing Resilient Community Spaces in Healthcare Facilities: An Exploratory Study of a Public Health Crisis

OBJECTIVES

This exploratory study aimed to investigate the impact of the COVID-19 pandemic on the design of healthcare facilities, particularly those featuring communal spaces. It sought to identify strategies that were implemented, learned, or recognized when adapting to the limitations imposed by protective measures during the pandemic.

BACKGROUND

Third places are social gathering places outside of home and work. Over time, these community-centric places evolved from free-standing getaways to more integrated niches in diverse contexts including healthcare. Their numerous advantages for users include enhancing community bonds and collaboration among healthcare workers. The onset of the COVID-19 pandemic resulted in a need to rethink the design of such spaces to make them more adaptable and resilient.

METHODS

An exploratory qualitative study was conducted through in-depth semi-structured interviews with sixteen practitioners involved in healthcare architecture and design projects during the pandemic. Data were analyzed using a thematic analysis approach.

RESULTS

Findings indicate that the design of shared spaces in healthcare facilities for pandemic-like situations requires a special focus on modifiability and multifunctionality, achievable through strategies such as the use of movable, unconnected, and rearrangeable furniture or partitions that could swiftly change the function of a space. Other strategies include the capacity for compartmentalization of spaces, fostering indoor-outdoor connections, integrating advanced technology, and implementing effective infection control measures. Detailed emergent themes and examples of experienced constraints are discussed.

CONCLUSIONS

Insights gained from our findings can be applied to new and ongoing healthcare design projects to ensure resiliency during normal and pandemic conditions.

Rethinking the Healthcare Facilities: The Role of the Buffer Space

OBJECTIVES

A working group conducted a survey on the use of the principle of buffer space (BS), which in case of emergencies, could benefit healthcare settings. The aim of the preliminary investigation is to define new research lines in hospitals' functional design.

BACKGROUND

The global experience of the COVID-19 pandemic highlighted challenges faced by hospitals when responding promptly to emergencies, including spatial reorganization and suspension of ordinary medical activities for ensuring adequate management of the emergency surge of patients.

METHODS

The group designed questionnaires to be administered to healthcare staff and healthcare designers aimed at understanding varied conceptions and features of BSs. Content across the two surveys overlapped significantly, allowing for direct comparisons of responses, while also including tailored questions in relation to the respective experience and skills of the two groups of respondents.

RESULTS

102 healthcare professionals and 56 designers took part to the survey. Analysis of the responses permitted for initial recommendations regarding BS typology including (a) proximity to the emergency department (ED), intensive care units (ICUs), and inpatient wards (IWs); (b) location within hospitals but separate from other medical areas; (c) need for independent access; (d) organizational and spatial features similar to ED, ICUs, and IWs; (e) existing as a fully flexible operational space; and (f) BS bed capacity to be approximately 12% of ED beds.

CONCLUSIONS

Although the analysis is related to the Italian context, the expansion of this preliminary research to alternate healthcare facilities and geographic areas is necessary for reaching a wide consensus by different professionals on this field. It serves as a starting point for future investigations regarding the implementation of BS in hospital settings.

Transforming health care systems towards high-performance organizations: qualitative study based on learning from COVID-19 pandemic in the Basque Country (Spain)

BACKGROUND

The COVID-19 pandemic is one of the worst health catastrophes of the last century, which caused severe economic, political, and social consequences worldwide. Despite these devastating consequences, lessons learned provide a great opportunity that can drive the reform of health systems to become high-performing, effective, equitable, accessible, and sustainable organisations. This work identifies areas in which changes must be encouraged that will enable health systems to deal effectively with current and future challenges, beyond COVID-19.

METHODS

A realist design was chosen, based on qualitative data collection techniques, content analysis and triangulation to identify key domains of organizational interventions behind the changes implemented to react to the COVID-19 pandemic in the Basque Country. Twenty key informants were used as an expert source of information. Thematic analysis was done using the Framework Method.

RESULTS

The analysis of the interviews resulted in the identification of 116 codes, which were reviewed and agreed upon by the researchers. Following the process of methodological analysis, these codes were grouped into domains: seven themes and 23 sub-themes. Specifically, the themes are: responsiveness, telehealth, integration, knowledge management, professional roles, digitisation, and organisational communication. The detailed description of each theme and subtheme is presented.

CONCLUSIONS

The findings of this work pretend to guide the transformation of health systems into organisations that can improve the health of their populations and provide high quality care. Such a multidimensional and comprehensive reform encompasses both strategic and operational actions in diverse areas and requires a broad and sustained political, technical, and financial commitment.

Decision Support Frameworks in Public Health Emergencies: A Systematic Review of Dynamic Models in Complex Contexts

Public health emergencies are extraordinary events of disease spread, with health, economic, and social consequences, which require coordinated actions by governments and society. This work aims to analyze scopes, application possibilities, challenges, and gaps of decision support frameworks in PHE management, using the components of the Health Emergency and Disaster Risk Management Framework (H-EDRM) and the Preparedness, Prevention, Response and Recovery Model (PPRR Model), providing guidelines for the development of new models. A systematic literature review was carried out using the Web of Science, Scopus, and Pubmed knowledge databases on studies published between 2016 and 2023, and thirty-six articles were selected. The outcomes show a concentration of frameworks on short-term emergency response operations, with a limited emphasis on the political and strategic components that drive actors and responsibilities. Management prioritizes monitoring, evaluation, and information management frameworks. However, the models need to overcome the challenges of multisectoral and interdisciplinary action, different levels of decisions and actors, data sharing, and development of common platforms of evidence for decisions fitted to the various emergencies.

Adaptability in healthcare buildings: a perspective through Joseph Bracops Hospital

The healthcare sector has to face changes happening fast and often in an unpredictable way, such as epidemiological trends, the advancements of medical technology and processes or evolving social and economic needs. This results in a frequent need for infrastructures' retrofitting, with an increasing focus on the environmental impact of buildings, which have one of the highest embodied carbon footprints per square meter in the construction sector. As result, interest in healthcare buildings' adaptability is growing among researchers and practitioners. After an introduction on the research topic, a focus on the definition of adaptability and the existing assessment models is provided to address the following research question: to what extent are adaptability models effective to evaluate and orient the design of healthcare buildings? A quite varied use of the term adaptability has been found in the literature, as well as a new research trend aiming to establish a link with circularity. Moreover, most of the assessment models do not have a focus and have never been tested on the healthcare sector. An approach to circular and adaptable design is presented through the case study of the Joseph Bracops Hospital (Belgium), which has been submitted for evaluation by the Reversible Building Design protocol developed by Dr. Durmisevic. The evaluation highlights some of the current barriers in the design of adaptable healthcare facilities. Insights for future research are provided to encourage data-collection about the service life of healthcare buildings, so to understand if the adaptability of these infrastructures should be mainly monofuntional or transfunctional.

Relationship between Racial Diversity in Medical Staff and Hospital Operational Efficiency: An Empirical Study of 3870 U.S. Hospitals

Demand for foreign nurses and medical staff is rapidly increasing due to the severe labor shortage in U.S. hospitals triggered by the COVID-19 pandemic. However, empirical studies on the effect of the racial diversity of medical staff on hospital operations are still lacking. This research gap is thus investigated based on the foreign medical staff working in 3870 U.S. hospitals. Results show that workforce racial diversity has a significantly positive relationship with hospital operational efficiency regarding occupancy rate, manpower productivity, capacity productivity, and case mix index. Notably, this study empirically supports that increasing the ratio of foreign nurses positively affects the overall operational efficiency of hospitals. In addition, the study results also indicate that the hospital location, size, ownership, and teaching status act as significant control variables for the relationship between racial diversity and hospital efficiency. These results imply that hospitals with these specific operating conditions need to pay more attention to racial diversity in the workplace, as they are structurally more sensitive to the relationship between racial diversity and operational efficiency. In short, the findings of this study suggest that hospital efficiency can be operationally improved by implementing workforce ethnic diversity. For this reason, hospital stakeholders and healthcare policymakers are expected to benefit from this study's findings. Above all, the results of this study imply that if an organization adapts to extreme external environmental changes (e.g., the COVID-19 pandemic) through appropriate organizational restructuring (i.e., expanding the workforce racial diversity by hiring foreign medical staff), the organization can gain a competitive advantage, a claim that is supported by contingency theory. Further, investors are increasingly interested in ESG, especially companies that embody ethical and socially conscious workplaces, including a diverse and inclusive workforce. Thereby, seeking racial diversity in the workforce is now seen as a fundamental benchmark for organizational behavior that predicts successful ESG business practices, a claim that is supported by stakeholder theory. Therefore, in conclusion, the findings of this study suggest that workforce racial diversity is no longer an optional consideration but should be considered as one of the essential determinants of competitive advantage in organizations, particularly in the healthcare sector.

Effects of a collaborative and gamified online learning methodology on class and test emotions

This study examines the influence of students' individual attitude and social interactions on participation in collaborative and gamified online learning activities, as well as the influence of participating in those activities on students' online class- and test-related emotions. Based on a sample of 301 first year Economics and Law university students and using the Partial Least Squares-Structural Equation Modelling approach, all the relationships among first-order and second-order constructs included in the model are validated. The results support all the hypotheses studied, confirming the positive relationship that both students' individual attitude and social interactions have on participation in collaborative and gamified online learning activities. The results also show that participating in those activities is positively related with class- and test-related emotions. The main contribution of the study is the validation of the effect of collaborative and gamified online learning on university students' emotional well-being through the analysis of their attitude and social interactions. Moreover, this is the first time in the specialised learning literature that students' attitude is considered as a second-order construct operationalised by three factors: the perceived usefulness that this digital resource brings to the students, the entertainment that this digital resource brings to the students, and the predisposition to use this digital resource among all those available in online training. Our findings aim to shed light for educators when preparing and designing computer mediated and online teaching programs that seek to generate positive emotions as a motivation for students.

The Wolfson Prize: designing the hospital of the future

Background

The 2021 Wolfson Economics Prize asked how new hospitals should be designed to radically improve patient experiences, clinical outcomes, staff wellbeing and integration with wider health and social care. With a major programme to rebuild and renew hospitals in England underway, the Prize offered an opportunity to understand current thinking about hospitals and their future place.

Methods

The 41 submissions that were identified as 'most promising' were reviewed and subjected to framework analysis. Emerging themes were identified and discussed iteratively.

Results

Five dominant themes were identified: a calming environment; systems of care; distribution of services; use of technology; and going green. Several tensions and trade-offs were evident across the submissions and a number of gaps were identified in the knowledge base that need to be remedied to ensure that new hospitals are safe and efficient.

Conclusion

The previous approach to building new hospitals, with its over-riding drive to reduce costs, has not served the UK well. New ways of thinking about hospital building and design are urgently needed, especially the funding of research and the creation of a national repository devoted to design solutions and post-build evaluations of new hospitals.

Responding to COVID-19: The Suitability of Primary Care Infrastructure in 33 Countries

COVID-19 proved that primary care (PC) providers have an important role in managing health emergencies, such as epidemics. Little is known about the preparedness of primary care practice infrastructure to continue providing high quality care during this crisis. The aim of this paper is to describe the perceived limitations to the infrastructure of PC practices during COVID-19 and to determine the factors associated with a higher likelihood of infrastructural barriers in providing high quality care. This paper presents the results of an online survey conducted between November 2020 and November 2021 as a part of PRICOV-19 study. Data from 4974 practices in 33 countries regarding perceived limitations and intentions to make future adjustments to practice infrastructure as a result of the COVID-19 pandemic were collected. Approximately 58% of practices experienced limitations to the building or other practice infrastructure to provide high-quality and safe care during the COVID-19 pandemic, and in 54% making adjustments to the building or the infrastructure was considered. Large variations between the countries were found. The results show that infrastructure constraints were directly proportional to the size of the practice. Better pandemic infection control equipment, governmental support, and a fee-for-service payment system were found to be associated with a lower perceived need for infrastructural changes. The results of the study indicate the need for systematic support for the development of practice infrastructure in order to provide high-quality, safe primary care in the event of future crises similar to the COVID-19 pandemic.

Hospital architecture in times of crisis

In times of crisis, such as public health emergency, military conflict or natural disaster, health systems face immense pressures. Large-scale crises continue to appear at irregular intervals and healthcare facilities should be prepared to react quickly and flexibly to the increased need for treatment and care. This paper aims to outline key concepts related to healthcare architecture during a mass-scale crisis, discuss challenges, and suggest solutions. Although the field lacks robust research evidence, lessons learned from past and ongoing events clearly indicate that advance planning is essential for effective crisis response. The crisis response has three guiding principles -adaptability, flexibility, and creativity. The interventions can focus on adapting existing healthcare facilities, building new units, and repurposing civil facilities for hospitals. A wide range of building typologies can be utilised, including modular containers, tents, lightweight structures, and repurposing civil buildings and public spaces. These interventions must be quick, economic, durable, and easily deployable. Temporary facilities must ensure an effective spatial platform for patients and staff, establish links with existing services, and consider post-crisis life of interventions. While these principles can be considered for any type of healthcare facility and any type of crisis, end-results will depend on baseline infrastructure and available resources.

Lessons learnt for enhancing hospital resilience to pandemics: A qualitative analysis from Italy

The COVID-19 pandemic has outlined the need to strengthen the resilience of healthcare systems. It has cost millions of human lives and has had indirect health impacts too. Hospital buildings have undergone extensive modifications and adaptations to ensure infection control and prevention measures, and, as it is happened following past epidemics, the COVID-19 experience might change the design of hospital buildings in the future. This paper aims to capitalise on the knowledge developed by the stakeholders directly involved with the hospital response during the pandemic to generate new evidence that will enhance resilience of hospital buildings to pandemics. The research adopted qualitative research methods, namely literature review and interviews with Italian experts including doctors and facility managers to collect data which were analysed through a thematic analysis. The findings include the identification of new needs for hospital buildings and the related actions to be taken or already performed at hospital building and service level which are viable for long term implementation and are aimed at improving hospital resilience to pandemics. The results specify how to improve resilience by means of structural modifications (e.g. placing filter zones among different wards, ensuring the presence of airborne infection isolation rooms at least in the emergency departments), technological changes (e.g. oversizing capacity such as medical gases, information technology improvement for delivering healthcare services remotely), and operational measures (e.g. assessing the risk of infection before admission, dividing acute-care from low-care assets). The needs discussed in this paper substantiate the urge to renovate the Italian healthcare infrastructures and they can be considered useful elements of knowledge for enhancing hospital resilience to pandemics in the extended and in the post-COVID-19 era.

The other side of the crisis: organizational flexibility in balancing Covid-19 and non-Covid-19 health-care services

Background

Many healthcare systems have been unable to deal with Covid-19 without influencing non-Covid-19 patients with pre-existing conditions, risking a paralysis in the medium term. This study explores the effects of organizational flexibility on hospital efficiency in terms of the capacity to deliver healthcare services for both Covid-19 and non-Covid-19 patients.

Method

Focusing on Italian health system, a two-step strategy is adopted. First, Data Envelope Analysis is used to assess the capacity of hospitals to address the needs of Covid-19 and non-Covid-19 patients relying on internal resource flexibility. Second, two panel regressions are performed to assess external organizational flexibility, with the involvement in demand management of external operators in the health-care service, examining the impact on efficiency in hospital capacity management.

Results

The overall response of the hospitals in the study was not fully effective in balancing the needs of the two categories of patients (the efficiency score is 0.87 and 0.58, respectively, for Covid-19 and non-Covid-19 patients), though responses improved over time. Furthermore, among the measures providing complementary services in the community, home hospitalization and territorial medicine were found to be positively associated with hospital efficiency (0.1290, p < 0.05 and 0.2985, p < 0.01, respectively, for non-Covid-19 and Covid-19 patients; 0.0026, p < 0.05 and 0.0069, p < 0.01, respectively, for non-Covid-19 and Covid-19). In contrast, hospital networks are negatively related to efficiency in Covid-19 patients (-0.1037, p < 0.05), while the relationship is not significant in non-Covid-19 patients.

Conclusions

Managing the needs of Covid-19 patients while also caring for other patients requires a response from the entire healthcare system. Our findings could have two important implications for effectively managing health-care demand during and after the Covid-19 pandemic. First, as a result of a naturally progressive learning process, the resource balance between Covid-19 and non-Covid-19 patients improves over time. Second, it appears that demand management to control the flow of patients necessitates targeted interventions that combine agile structures with decentralization. Finally, untested integration models risk slowing down the response, giving rise to significant costs without producing effective results.

Analysis of Functional Layout in Emergency Departments (ED). Shedding Light on the Free Standing Emergency Department (FSED) Model

The ever-increasing number of hospital Emergency Department (ED) visits pose a challenge to the effective running of health systems in many countries globally and multiple strategies have been adopted over the years to tackle the plight. According to a systematic review of the available literature, of the numerous models of healthcare systems used to address the issue in western countries, the FSED Model has the greatest potential for reducing hospital ED overcrowding as it can reduce the additional load by diverting minor cases, freeing up space for more urgent cases. The aim of the study is to shed light on the Free Standing Emergency Department (FSED) model and compare it with the traditional Hospital Based Emergency Department (HBED) in international contexts. In this study, 23 papers have been collected in a literature review and the main features have been highlighted; 12 case studies have been analyzed from a layout point of view and data have been collected in terms of surfaces, functions, and flow patterns. The percentages of floor areas devoted to each function have been compared to define evolution strategies in the development of emergency healthcare models and analyses. The use of FSED models is an interesting way to face the overcrowding problem and a specific range for functional area layout has been identified. Further studies on its application in different contexts are encouraged.

A Review on Building Design as a Biomedical System for Preventing COVID-19 Pandemic

Sustainable design methods aim to obtain architectural solutions that assure the coexistence and welfare of human beings, inorganic structures, and living things that constitute ecosystems. The novel coronavirus emergence, inadequate vaccines against the present severe acute respiratory syndrome-coronavirus-(SARS-CoV-2), and increases in microbial resistance have made it essential to review the preventative approaches used during pre-antibiotic periods. Apart from low carbon emissions and energy, sustainable architecture for facilities, building designs, and digital modeling should incorporate design approaches to confront the impacts of communicable infections. This review aims to determine how architectural design can protect people and employees from harm; it models viewpoints to highlight the architects’ roles in combating coronavirus disease 2019 (COVID-19) and designing guidelines as a biomedical system for policymakers. The goals include exploring the hospital architecture evolution and the connection between architectural space and communicable infections and recommending design and digital modeling strategies to improve infection prevention and controls. Based on a wide-ranging literature review, it was found that design methods have often played important roles in the prevention and control of infectious diseases and could be a solution for combating the wide spread of the novel coronavirus or coronavirus variants or delta.

The Built Environment Influence on Resilient Healthcare: A Systematic Literature Review of Design Knowledge

OBJECTIVE

The aim of this study was to develop built environment (BE) design knowledge to support resilient healthcare by systematically reviewing the evidence-based design (EBD) literature.

BACKGROUND

Although the EBD literature is vast, it has not made explicit its contribution to resilient healthcare, which is a key component of the highly complex health service.

METHOD

This review followed the steps recommended by the Preferred Reporting Items for Systematic reviews and Meta-Analyses method. After applying the inclusion and exclusion criteria, 43 journal papers were selected. The papers were analyzed in light of five guidelines for coping with complexity, allowing for the development of BE design knowledge that supports resilient healthcare.

RESULTS

The design knowledge compiled by the review was structured according to four levels of abstraction: five design-meta principles, corresponding to the five complexity guidelines, seven design principles, 21 design prescriptions, and 58 practical examples. The design knowledge emphasizes the interactions between the BE as physical infrastructure and the functions that it supports.

CONCLUSIONS

The design knowledge is expected to be useful not only to architects but also to those involved in the functional design of health services as they interact with the BE. Furthermore, our proposal provides a knowledge template that can be continuously updated based on the experience of practitioners and academic research.

Responsiveness and Adaptability of Healthcare Facilities in Emergency Scenarios: COVID-19 Experience

The COVID-19 pandemic revealed many vulnerabilities of the contemporary built environment along with limited preparedness and low efficiency in mitigating unexpected and unprecedented challenges. This article discusses the efficiency and responsiveness of basic hospital spatial layouts in three different scenarios: normal operation; the segregation of a large number of patients and still providing them with access to emergency healthcare, typical for a pandemic; and a sudden, extremely high number of admissions typical for compound disasters and terrorist attacks. A set of parameters and a method for general adaptability assessment (GAAT) that can be used as a tool in decision-making processes as well as evaluation of both existing facilities and the new models for resilient hospitals resulting from the experience of the pandemic are proposed. The paper emphasizes why factors among which adaptability, convertibility, and scalability should be at the very core of hospital development and management strategies. It also discusses new models of adaptable healthcare facilities that enable day-to-day operations to continue alongside a pandemic, and other emergency scenarios.