What happens when you hold a contest and no one wins?
The challenge laid out by the HAIO was simple: design a better patient room, melding infection control with patient comfort. Picking a winning design was anything but. Seven of the top architecture firms in Boston submitted designs. Each was unique and innovative—so much so that the collaborative soon understood that a real winning design would involve elements from all seven submissions. "We looked at it as a series of great ideas," said Alison Faecher, IIDA, principal interior design, SmithGroupJJR. "Which I think was the most important part."
HAIO decided to make patient safety the winner. What started as a competition became a collaboration. Architects at the height of their careers put ego and professional competitiveness aside in order to make the hospital a safer place for patients. "As architects we consider ourselves support to the healthcare team," explained Teresa Wilson, AIA, principal, Steffian Bradley Architects. "We're trained to work collaboratively with people from hospitals. But working collaboratively with our peers, we aren't asked to do as much. That's what was so enjoyable about this to me." So, what happens when you hold a contest and no wins? Maybe, everyone wins.
Making Patient Safety the Winner
The HAIO group was formed in 2010 by Peter Slavin, the president of Massachusetts General Hospital, and charged with discovering what could be done on the design end to make hospital rooms easier to clean and reduce the incidence of HAIs. The initiative brought together epidemiologists, infection control specialists, environmental staff, and healthcare architects.
At first, the group functioned as a sort of think tank. The members extensively reviewed literature. They assigned themselves homework. They studied presentations from infection control experts. But when renovations began on an oncology floor at Brigham and Women's Hospital, which like Massachusetts General is part of Partners HealthCare, HAIO leadership proposed the challenge. Seven architecture firms entered designs. The winner would be granted the opportunity to create a template room on the renovated floor.
The submissions had similarities, but each was unique in its own way. One proposal focused on creating rooms with separate entrances and exits to ensure that the flow of people always went the same way. Another design was centered on simplicity. Still another highlighted ways to improve hand hygiene. Settling on one design would have ignored useful elements from the six others. Eventually, the group decided to combine forces. To modify an old saying, surely seven heads were better than one.
What followed were six four-hour meetings, during which the architects, now working together, shared their expertise to develop the perfect patient room. Along with making patient safety the real winner, this collaboration offered the architects a chance to see how their peers think—to work with potential colleagues whom they might otherwise only pass in the hallway on the way to a prospective job. "Being a healthcare architect is something you fall into," reported Cathleen Lange, AIA, principal architect at Shepley Bulfinch. "This is the kind of work we love to do. The opportunity to collaborate and learn from each other was pretty exciting. The sessions were really unprecedented."
Once again, the architects heard from infection control experts. They received an advanced course on what it means to be evidence-based. They were encouraged to "steal" from each other. Once again, they did their homework. Infection control staff from Partners HealthCare reviewed each contest submission and divided the proposed concepts into the following "buckets":
Facilitates room cleaning—Example: Smooth headboards
Facilitates equipment cleaning and management—Example: Self-contained bedpan washers
Minimizes splash/touch contamination—Example: Hands-free doors
Encourages hand hygiene—Example: Handwashing monitoring systems
Improves waste management—Example: A separate alcove for soiled linen and waste
Features from the original proposals were kept in the buckets if they were feasible and easily implemented. Ideas that the reviewers found interesting and potentially worthwhile for the prototype room included:
- Locating handwashing sinks away from patient zones
- Installing hands-free doors
- Using rounded corners to facilitate cleaning
- Building smooth headboards without elaborate designs or dust-collecting shelves
- Replacing traditional curtains with digital e-glass
- Incorporating visual cues for hand hygiene
- Installing automatic bedpan washers
- Incorporating bathrooms that can be accessed for cleaning from the outside without entering the patient's room
The HAIO collaborative recommended visual cues for hand hygiene. Audio cues may also help—for instance, consider installing a hand hygiene compliance system that beeps when someone walks past without washing his or her hands. While these systems are intended to audit compliance, they can also be effective when used to provide a reminder, the way a car beeps if someone isn't wearing a seatbelt. "It's not so much even a matter of forgetting to wash your hands," explained Carol Clark, BSN, RN, MJ, an ECRI Institute patient safety analyst and consultant. "You're pushing a cart into a room, you're running through all the logistics of what you need to do, and then a little something beeps. It's a gentle reminder to stop and wash your hands."
Ideas that the reviewers found questionable for the room included removable furniture coverings, innovations that were too technology-dependent, copper and silver surfaces, antimicrobial surfaces, and laminar air flow. Some of these suggestions were questioned because they were too expensive, others because their claims were the result of marketing and not evidence-based. "It's pretty rampant in the industry," noted Paula Wright, RN, BSN, infection control specialist at Massachusetts General Health, referring to marketing influence. "When people look at a product and the marketing says that this product will reduce your HAIs by x, y, and z, or it's going to solve all your cleaning problems, you should be pretty skeptical."
Incorporating everything into the template room also required a reality check. Some ideas had to be scrapped to fit into the footprint of a small, wedge-shaped room that dated to 1979. Everyone agreed that bathrooms that could be accessed from the hallway would be ideal, but the setting made it impossible. The same applied to creating a room with unidirectional flow, meaning that staff and visitors enter through one door and out the other. "These are things that can be taken forward and used when building a brand new hospital and the sky is the limit in terms of what you can do," Wright said.
While the idea was not feasible in the template room, the HAIO collaborative loved the notion of a bathroom that could be accessed from an outside door, because it could be cleaned more easily. Clark pointed out this could also facilitate a quicker response to a patient who needed help. "Think about it," Clark said. "You're outside and you hear 'thump,' and you run in. You're saving precious moments."
The original proposals also included a good deal of crossover when it came to installation of smooth, monolithic, and high-tech surfaces. These surfaces are slick and easy to clean. However, the price was too high. The project had to be scaled back to reality. The members hope that the HAIO collaborative continues and look forward to the chance to design a larger patient room and implement some of the ideas that were deemed infeasible for this project.
The project resulted in several key lessons learned.
Don't Believe the Hype
One of the major takeaways was the influence that marketing exerts on design decisions. "That really opened everyone's eyes," Lange observed. "This is not just limited to architects. It's very easy for people to become interested in all the various specialty items and coatings and materials with all these unsubstantiated claims attached to them. You have to look at the evidence behind them."
Just because a cleaning product costs more money, don't think that means it will be more effective at reducing HAIs. Bleach is often as effective a disinfectant as a cleverly marketed cleaning product, Clark said. Just like pharmaceutical companies, cleaning supply companies spend money on marketing. Often, that marketing cost is passed to the consumer.
"The truth is there's no magic bullet," Clark said. "You're still going to have to do your due diligence."
Keep It Simple
The simplicity of solutions stuck with the participants. Many of the original designs were looking at high-tech products with high price tags. But often the best ways to improve patient safety were the most straightforward, such as:
- Finding ways to limit contaminants from entering a room
- Providing a separate location for people to store their coats
- Locating the sink in the correct place
- Paying attention to corners and making sure they are easy to clean
- Incorporating surfaces that are durable and easy to clean
- Paying attention to high-touch items
Or as Wilson suggested, "Just keep it simple."
The reason behind limiting high-touch items is straightforward. Fewer items for people to touch means fewer opportunities to transfer germs. One way to accomplish this, Clark suggested, is to install motion-activated lights. In order not to disturb sleeping patients, install a light next to the bed that can be activated by a hand wave. Another possibility is to install a voice-activated room phone. Hands-free doors are also worthwhile. "Even if you're inoculating the doorknob, you might touch something else," Clark said.
This does not mean that all high-tech, expensive products should be avoided. The HAIO group liked the idea of replacing curtains with digital e-glass. This idea would be expensive up front, but glass is much easier to clean and needs to be replaced far less frequently than curtains would, Clark said, which could save money in the long run, because it's a one-time capital investment.
Check the Guidelines
Infection control personnel may be tempted to consider expensive and slickly marketed antimicrobial sinks. However, guidelines exist for a reason. A sink should be built and installed according to Facility Guidelines Institute specifications, which call for minimizing splash and hanging it away from supplies, Wright said. As Lange explained, "We'd bring ideas to the meeting and talk about them. Then, frankly, we'd get a bit of education from the infection preventionists on why that very expensive, funny-looking sink might not make a difference." The HAIO group found that simply separating the handwashing sink from a work zone likely improves patient safety more than an expensive antimicrobial sink.
It wasn't just the architects who learned lessons. Hospitals can learn from projects like this, too. Infection control specialists may be tempted to demand a sterile room that is so inhospitable to germs that it also becomes inhospitable to patients. "If I could, I'd make an all-stainless-steel room that you can hose down," Wright said. "That way you don't have to worry about mold, mildew, wet sheetrock, things like that. But I learned from the architects about the impact the environment can have on patients and their emotional well-being. This did help to widen my viewpoint of room design." The key is to remember that trade-offs are inevitable. "Sometimes the solution isn't a perfect one," Clark noted. "A certain level of risk might be necessary to achieve the balance and benefit. In the end, you just have to do what's best for the patient's safety."
As of June 2018, the room had been designed, completed, and was awaiting its first patients. Architects from as far away as San Diego have contacted members of the collaborative at conferences to ask if they can replicate a similar project. "First and foremost you need a champion," Lange said. "In our case that was Partners HealthCare."