Oh.

howdy.

Are y'all doing good?

Good.

So today we have Doctor Nora Coleman joining us.

Doctor Coleman is a pediatric intensive care physician.

So she's not joining us today.

And she works at Children's Health Care of Atlanta.

She has also worked there as a simulation fellow and she has a passion for health care simulations and integrating their role in improving safety in healthcare facilities.

And today, she has joined us to discuss how we can effectively engage clinicians in design through simulations.

So please help me welcome Doctor Coleman.

Thank you guys for having me.

I'm really excited to be here today.

Please feel free to interrupt.

I know we have some time to talk after the lecture, but if you have questions, you won't throw me off so you can raise your hand or just speak up and interrupt me as we go along.

So today I'm going to talk about how we can design safe hospitals and, bring some clinician perspectives.

And we're going to talk about, some concepts in patient safety, a little bit about human factors and achieving operational excellence and what that actually means for hospitals.

So I work at Children's Health Care of Atlanta.

I'm a pick U physician.

But I also am really passionate about the intersection of, facility design and the built environment space on patient safety and how we operate.

So, I tell you, talk a little bit about how I got there.

So we're going to talk about patient safety principles, the role that human factors play in space utilization, clinical operations.

And I know you guys are sounds like super interested in technology.

So I'm going to show you some of the realities of technology.

And we're going to talk very briefly about how the built environment impacts, caregivers, meaning staff.

So how did I get to, being interested in designing hospital?

So, I always knew I wanted to do pediatrics.

I did my critical care training, and, Atlanta.

And then I was always interested in simulation.

So really, how do people how do we train people to work together?

How do we kind of organize and orchestrate, a team?

And how can we do that in a simulated environment so that we're testing and working through things on a mannequin, and we can mitigate risk before we are actually doing these things on patients?

And then, we started to build a new children's hospital.

My mentor was like one to mock it up in cardboard and do sim.

And I was like, definitely.

So I actually stayed, an extra year at, Koa and I did a simulation fellowship.

So we spent about a year and a half doing SIM testing for our new hospital.

So I'm going to show you some pictures from simulation, but we basically built a 100,000 square foot mock up in a large warehouse, and we tested a bunch of clinical areas and really got the clinical perspective.

And so that's kind of where my journey into design, really started.

I'll just say, before I started doing this work, I don't even think I really paid attention to architecture as a thing at all.

And I've learned so much in the past few years about built environment and the impact of space on people.

But as a clinician, we don't know anything about architecture.

We don't know anything about the built environment.

We don't talk about it and we certainly don't understand it.

So I hope to provide that perspective for you guys today so that as you get into your career, you can really understand where some of the gaps are, in the intersection of healthcare design.

So we all know that healthcare is risky.

This came out about 1999.

About to is human wrecking izing that healthcare is not safe and that there is a lot of adverse events that happen.

We know that thousands and thousands of people are harmed by healthcare related errors, and we know that these cost the health care system and organizations billions upon billions of dollars.

So this call was really to, a call to action to improve safety through safe practices, through tracking errors, through transparency and accountability.

But as you'll see today, the our slogan at children's is one is not zero.

And we really have yet to reach zero harm.

So adverse events in hospitals and health care are continuing to happen despite, all of the work that we've done to try to improve patient safety.

So maybe some of you remember this from the Hudson when we, when the plane got landed safely.

Right.

The airline industry is what we call Six Sigma.

So are you guys familiar with this term at all?

But it basically means that for a billion opportunities, there's only about three defects.

So how many flights take off in the world a day?

I don't know, but it's probably billions.

And how many aircraft flight crashes actually occur?

Very few.

Right.

And so the airline industry has really achieved Six Sigma, which means almost negligible harm.

We are so far from this in health care, although we strive to be Six Sigma, the reality is we probably are never actually going to achieve that goal.

I'll talk a little bit about why.

So health care is extraordinarily complex.

And the patients we take care of don't always follow our textbook.

In fact, most of the ones I take care of have never read a textbook.

And so all the things I learned in school, you kind of have to adapt, to what's happening in the moment and take what you learn in the textbook in which you learn about physiology and be able to apply and adapt to the patient.

So no patient presents the same.

No patients needs are the same, and they change really rapidly.

So you might have a patient that's doing okay one minute and that's really sick the next.

And they change in really unexpected and dynamic ways.

And so we can't do we have a lot of checklists in health care.

But a taking care of a human is different than flying a plane.

Right.

You can do all the checklists in the world your patient still might not abide, but what by what you expect.

And so that contributes to how hard it is to reach a six sigma and zero harm kind of state.

And like I said, there's a lot of variability, in patient condition.

So their diseases are different.

Their needs are different.

You're taking care of humans and everybody has different needs in terms of both what their experience is like, but also how their disease presents itself.

And so we talk a lot about disease heterogeneity.

And when you think about the built environment, we talk a lot about standardization too.

Right.

And so the question that is always at the top of my mind is how much can you standardize the built environment and standardize your patient care.

And those are really dichotomous things, because at the end of the day, there will be no way to always to completely standardize how we deliver health care.

And that because disease process and patients are different.

And so that's always a fine balance in architecture.

Can we standardize environments to minimize how complex our care delivery is?

And how do we balance those two things?

Does anybody know kind of what human factors are?

You ever heard of it.

Heard the term.

So that's perfect because this is why I talk about human factors.

So human factors really look at the way humans interact with their spaces.

How do they how do we interact with our environment.

How do we interact with technology, how do we interact with equipment.

And it really considers human behavior.

And have you I guess, anybody got a new iPhone recently?

I did, I had to read like YouTube videos and like, not everything's super intuitive.

Right?

So it's the way that I interact with my device, right?

Or have you ever, like, walked across a, a parking lot and you see that there's, like, a path that's paved and then there's like a space in the grass where everybody's cut across the pathway that's human factors, right?

We're going to take the path of least resistance.

And we're going to create workarounds in doing that so that we can make our way around limitations in our environment or around limitations in technology.

So human factors and user centered design is something that's very common in like, technology industry, device industry, but it's really not so common in healthcare.

It's becoming more common.

And we're talking about it more, but it's been really, really important to think about how is a human going to interact with the environment that you're building?

Are you going to create a space, and is your human going to use that space as you hope they would?

The likelihood is they're probably not right.

And that's because, there is some human behavior component to how they're going to live in the environment that you build.

And so it's really important to understand how this dynamic plays into healthcare and how humans are going to interact with your space.

And I will show you a few examples.

And then we also have to, of course, think about the patient and what their needs are.

We have to provide patient centered care, compassion.

And there's a lot of ethical considerations, that go into care delivery.

Has anyone heard this concept?

Complex adaptive systems.

Okay, so, this means that nothing in healthcare works in a linear relationship.

So if I change a piece of technology, it's going to interact with all of these other elements and it's going to impact care process and it's going to impact health care outcomes.

So this framework is also based on the CPI 2.0 model, which really helps us to define what is in a work system.

So our work system is the built environment which we are going to focus on today.

But it also includes pieces of technology which we'll talk about.

And I know you guys are super interested in Tash, like what are clinicians actually doing?

The people that work in that space and organization.

So what's the organizational infrastructure?

What's the culture?

All of these kind of things intersect.

So if I change one thing in my environment, it's going to have potentially complex downstream implications.

So if I change the environment that might change how my technology integrates or how my people interact or utilize that space.

And as we think about mitigating risk or, improving patient safety, we have the opportunity to do this in a proactive way.

So usually in healthcare, we're super reactive.

We love to just fix problems after they happen instead of before.

So we often start with a health care outcome like there was a bad event that happened.

A patient was harmed, a patient did not survive.

Right.

And then we go backwards.

We'll say, okay, was there a problem with the process?

Maybe we'll get to the get to the work system elements, but we rarely even get that far.

So the whole idea of doing simulation and kind of mock up work, is to really go forward.

So start with the built environment and see how we can augment care.

And can we actually impact, patient safety and improve outcomes for our patients.

So this is a term that, not a lot of people actually talk about, but I think it's really important.

So as you're, creating spaces, you're a clinical teams.

We have to adapt on a constant basis.

Like I might be having a fine morning getting my coffee.

Maybe I'm tired, and then the code alarm goes off and I need to.

I need to sometimes throw my coffee on the floor, leave it at the coffee shop and, like, turn on my brain and go do something really complicated, right?

That means I had to adapt to that change in my environment, or I moved into a new hospital.

Now I have to adapt to a whole lot of things like new technology and a new physical space and new staff.

It's a lot, right?

So adaptive capacity is how much, how much resilience do I have as an individual, as a team, as a system to actually be able to function at the highest level with all of these changes happening, Covid was like the prime example.

Health care did a pretty good job considering how bad Covid was, right?

We adapted to constantly new information, new medication, new diseases really quickly.

But for systems that didn't have a lot of adaptive capacity, patients didn't get great care and staff got burned out.

Right.

And so, you start as you think about creating flexible spaces, this is a super important concept to also think about if you want to create a universal room.

Well, can your staff, you take care of different types of patients.

Can I can that one person take care of a like low acuity patient and a very high acuity patient?

Usually the answer is no.

And so that is kind of how that design and care delivery intersect.

Does that make sense?

Okay.

Workarounds.

So this kind of goes back to like walking across the green pathway instead of what's paved.

Right.

We are always going to do what's easy for us, even if that means it's not the best thing.

So I'll give a good example of like just everyday work around the old hospital I worked at had a lot of traffic, so.

But I did not really want to get up 30 minutes early to like beat the traffic.

So I would leave at the same time every day.

And instead of, like waiting at a traffic light for 20 minutes, I would like cut and cross this, like Dunkin Donuts parking lot.

It was like a disaster waiting to happen because, like, you're not supposed to cut across a parking lot to make a right turn with all of this traffic coming up, there is a risk in doing that that I would get hit and then I would be in the wrong way because like I was doing the wrong thing.

Right?

But that made my and maybe cut like two seconds off of my drive.

But it was worth it to me.

Right.

So that's a workaround.

But the workaround is deviance from doing what's right.

And within that deviance is space for risk.

Does that make sense?

Questions.

Because it's important.

This is what is going to happen in the spaces you design okay.

You're going to design a great hour.

You're going to design a great ICU room.

And then your clinical team is going to come in and they're going to be like, that doesn't work for me, and they're going to do something that's actually unsafe.

So, we had we had expanded in our old ICU, like made new beds, made new rooms.

They didn't have enough suction outlets.

So I found out actually in SIM that the nurses are, like, weighing in the suction and like, running tubing under the bed.

I had no idea that they were even doing that, but it becomes so normal to them that they didn't even.

They were like, why would I tell you?

Like, that's just what we do.

You say, set up the room.

I set up the room.

We didn't have enough sections of to y stuff in and run cords all over the place.

And this is what they're going to do, because at the end of the day, I have to take care of the patient, irrelevant of my environment.

Right.

And so we're going to take the path of least resistance.

And that's where risk happens.

Okay.

So how do we get from a mock up.

So this is our mock up back in 2019.

And this is our new hospital.

So it's a pretty big jump right.

It's kind of been fun to see the evolution.

But how do we get here.

So I want to talk a little bit about some of the frameworks, that we use and that I hope to give you guys some of these tools so that as you start to do research in your in mock up space, you can utilize some of these concepts.

So this is, is everybody familiar with evidence based design.

Yay okay.

Great.

Awesome.

So this comes out of the center for Health Design and H.R.

Q and there's been a lot of work has been done in this area, which is fantastic for us as a clinician working with architects, right, that there is a body of evidence that's out there and we can put we can use this as a framework for simulation testing.

So these are ten principles and these are standards.

We know that these principles impact health care outcomes.

So if we use this as a framework to do simulation, we know that as we're testing the space, we're looking for latent conditions or kind of those holes in the system that can cause harm later on, that we're trying to minimize or optimize these things in design.

And if we can get some of these things right, we know that we're going to have an impact on the space.

So like visibility is a great one.

There is so much data about how sightlines are going to, improve patient safety.

And so if we have poor sightlines in our space, it's likely that there's going to be some kind of accident that happens.

So if we can get into a mock up space and really think about visibility and our sightlines and fix our design so that we can see into the patient room so we can see down the hallway, then we know there's an opportunity to actually improve outcomes.

Make sense?

Okay.

So a little bit is kind of similar about, human behavior and human factors.

So as we go through simulation, these are the things that we're uncovering.

We're starting to understand how the humans that are going to work in the space of design are actually going to use it, and you're going to start to see gaps, right?

You're going to be like, that is not what that is for.

And the nurses are going to tell you why, like, I have no place else to do my work.

So like I'll give an example.

The nurses in the ICU always need place to do clean work, like drop medications.

But technically, if you're only space to do work is by the sink, that's where they're going to do it, right?

But that's known is actually not best practice because of the splash zone.

Right.

So that's that space that looks clean is actually super dirty.

But the nurses are going to use that space and you're gonna be like, that's not what that space is for.

I built you a med room down the hallway that has a nice clean countertop in it.

And here you come, drawing meds by the sink.

Right?

So those are some of the things, human factors, because it's easier for them to do it closer to the patient.

And there might not use your design as you intended.

Has anyone heard of the Swiss cheese model?

Yeah.

Great.

Okay.

So it applies to design, obviously.

So if we don't get the design right, we don't have standardization, we don't have the best adjacency layout.

We have environmental hazards.

If you pair that with an error provoking condition like I'm tired I'm over it.

I didn't communicate effectively.

That's one other hole in the Swiss cheese.

And then if you pair that with an active failure, like I just blatantly didn't do what I'm supposed to do.

Then you actually have an accident happen.

Make sense?

So, systems engineering, this idea of, this how we look at a system as a whole, how we incorporate human factors, becomes a big component of the work that we do in SIM and augmenting patient safety.

So have we reached zero harm?

Definitely not.

Right.

So why?

Like, we've done a lot of work.

There's a lot of research, both in evidence based medicine and safe practices and hand hygiene compliance and all that stuff.

And there's a ton of research and architecture.

So why haven't we just gotten it right yet?

Right.

So for a few reasons, we will always have workarounds.

We will always go, oh, stray away from your design intent.

And, there is always going to be environmental hazards in our system.

So, gonna dive into a little bit of these things.

So what do you guys see?

A brain, a brain.

Great.

Do you know what's wrong with it?

Do you know how to treat it?

Do you know what the prognosis is?

Do you know what the evidence based medicine is around how I treat this right?

I wouldn't expect you to.

Right?

When I look at this, I see a brain.

I see like a really horrific head bleed.

And I have a whole thing that I'm going to need to use a whole algorithm and data set of how I treat and take care of this patient.

I have a sense about prognosis.

I have, well, a soft sense about prognosis.

But I have to tell a family a story, right?

I have to tell them what's going to happen, what I'm going to use to treat their patient.

So this is how you think about how you feel when you look at the CT scan.

This is how we feel when we look at a drawing.

Absolutely have no idea what you're talking about okay.

Like I, I when I so now I've looked at a lot of drawings.

I'm a little bit better than I was at it before.

But when we first started simulation I was like, I mean, this is like, this literally means nothing to me.

I have no idea how big this space is.

Let me tell you, this space is massive.

But looking at it on a paper, I'm like, maybe it's the I don't know, right?

I have no I can't tell you.

I'm like, are those.

So I hear clinicians say like, are those doors or those alcoves?

Like, what does that acronym mean.

Is that an where is the stairs?

Where's we.

Nothing.

Okay.

So just think about what it means for you to look at a CT scan when you start to intersect with clinicians and you start talking drawings and space.

It's like how you feel right now.

Okay.

So we cannot image imagine space utilization like at all.

And it's like a real gap in particular for clinicians.

I don't know, we're like really bad at it.

I think we're probably worse than other, industries and other people and, that do things outside of medicine.

So we cannot imagine square footage, like, do y'all know how big this room is?

I don't know, because I have literally no idea, but I've learned to count, ceiling tiles.

Do you guys have a sense of square footage?

Yeah.

Okay.

Me?

Nothing.

I have no sense.

Okay, you could tell me this is 1000ft².

I believe you.

Or you could tell me it's 200 and I would believe you.

I kind of know now it's not 200, but beyond that, I have no idea.

Okay.

So hallways and corridors, I can tell you.

Okay, that's a right angle turn, but, like, how wide they are, how it connects to spaces.

By looking at a map, it's really hard for me to imagine what that would look like if I'm actually walking in the hallways.

It's hard for me to understand adjacencies, like, okay, if, my, my room trauma room is here, like, where is my imaging hat?

What hallway do I have to take to get there?

How did those relationships kind of intersect?

And so this is what we're going to ask because we don't understand.

We're going to ask, well, how does that size of what you're showing me compared to what I have now?

So they always you always need a spatial comparison.

So you will forever be going back.

If you end up working on the client side of architecture, you will forever end up going back to the current building and looking at every single space, because they will always ask you, well, how big is my supply room now?

And how big is my O.R.

now?

And how big is my patient room now?

Because that's the only way we can compare it.

And we have no idea what your acronyms mean, either.

So people don't know what, like where the toilets are.

They don't know where the infection isolation rooms are.

They will ask all of those things.

So again, we cannot imagine how we're going to actually deliver care in the space.

And so we actually get into the space and use it.

So and it's even still a jump to do it in a cardboard mock up, like there is still a gap between cardboard mock up and actuality.

So why can't we imagine so a few concepts.

So, Erica Nagel has this quote, and it's one of my favorites, but it's impossible in practice as well as in principle, precisely to prescribe how work is done.

So all of the architecture work is asking us to imagine what it's going to be like to take care of a patient in that space, even if we're doing process work, or flow diagraming all of that is imagined work.

And then you put all the things we've talked about complexity, human factors, work arounds, the system into this space, and all of a sudden it's nothing like we imagined.

So I'm going to show you this video.

So this is, a detailed design drawing.

So we were like sitting with the architects, like, where does your stuff need to be?

Okay, fine.

Then we get into a simple mock up and they put the bed in the room, they throw some equipment in there, and everybody's like, it should work, right?

We're like, sure, I guess sounds good.

Then we put a then we put a simulated, a complex simulated scenario into this space.

And this is what happened.

And I don't think I don't know if there sound, but what I'll do is narrate because it's, so this is a baby, mannequin.

But it actually happens in real life, who's extremely sick and basically needs to go on full cardiac like heart and lung bypass to save their life.

So the team has to change out of bed because the crib is too small.

And what do they do?

They you saw them lift the baby on the backboard.

This still happens because somebody makes cribs where the rails don't go down and when they're attached, and I every time they're in my ICU, I like literally have a meltdown because I'm like, I have told you guys to get these cribs out of my unit because we're constantly having to.

All of your lines are connected to get the kid off the crib.

You have to pick them up over the crib, right?

If you can imagine.

So if I'm doing imaging or anything that needs to move these patients, they have to go up and over human factor failure.

Right.

Or usability testing failure.

And so they literally are picking this kid up, turning them around the whole room has to rotate in like simultaneously.

And this kid, this is a baby that's small.

So the everything attached to this infant is short and small.

The tube in the mouth that's letting them breathe is short.

The circuitry to the vent is short.

And so if anything comes out, which it can, that patient can die.

And I know that's terrible.

It's the truth.

Obviously, I'm going to give you the unfiltered version of life.

Okay.

That patient can die in this moment.

It's extremely high risk.

Okay.

So can we design a space so that this part of my life can be less complicated?

And that is, that question has no answer.

Questions or thoughts?

Okay.

And like I said before, like, care is complex.

So if you put a bunch of clinicians around a table and like, tell me what a worst day in your life looks like, they'll give you maybe, I don't know, 10% of the picture of what it really looks like, because this is what we just do.

We just do it right.

So if you if you want to know, well, how many tubes are they attached to and what are they attached to and who's in their room and what equipment in their room.

You're really not going to get the full picture because we're not even paying that much attention.

We're just doing all of these simultaneously.

We're very task and process oriented, but we can't really articulate this level of complexity.

And then human factors are always going to be at play in health care.

So the question for you guys is can you create an environment that drives human behavior to do the right thing without having to teach humans to do the right thing?

That is, if you can figure out how to do that in design, your impact will improve patient safety or outcomes for the life cycle of that building.

So what do I mean?

So, has anyone ever been in an MRI scanner?

Okay, you've been in it.

What is it like in there?

Therapy.

Yeah, right.

Did they have to did you have to change your clothes?

Yes.

Yeah.

Did they want you?

Yeah.

Was it like going through TSA PreCheck but not the PreCheck lane?

Yeah.

So MRI is like the highest environmentally risky area in the hospital.

And that's because it's the gigantic magnet, right.

So if you are so you had to get wanded and screened and you had to put on clothes that didn't have any kind of ferrous material in it so that your stuff couldn't get sucked into the magnet.

You don't want equipment getting sucked into the magnet either.

So you really this space is really, really dangerous.

And if you're on the scanner, can you imagine being on the scanner and an IV pole flies into the core of the scanner, like, right.

Catastrophic.

Those are catastrophic outcomes that can happen.

So can we design the space so that we're not relying on humans to remember to do stuff that keeps us space safe.

So we have I mean, I cannot tell you the number of processes and protocols we have for MRI, like you've already experienced it, right?

So we have zone based layouts.

So you can't get into the the scan room unless you've been wanded, unless you've done an MRI screening, we've made sure you don't have any metal in your body outside of your body.

And that's one process.

And then we want everybody we have all of these operations.

We have screening forms.

We try to standardize all this stuff.

Y'all got to.

Yeah.

What happens if you have like screws in your knee or something like that.

Are those nonferrous.

Yeah.

So they have to be.

So I just had plates put in my wrist and they are ferrous free.

So unfortunately I can still go into the MRI scanner.

But yeah.

So you do need to know though if you ever have plates or anything if those plates are ferrous free or not.

And usually they will wand you if you don't know.

And if it beeps, they're not letting you in the scanner.

If you are need any like anxiety medicine to get in the scanner and you have braces, they won't let you in.

So if you're sending it and you can't say like my mouth is on fire, you cannot get into an MRI scanner with braces because it's not ferrous free and it will actually burn the inside of your mouth.

Yeah, so I've had to rip braces off.

Kit.

It's a whole thing.

It's the orthodontist are not happy when we take braces off of our patients.

But yeah, but it's a great question.

So and there are stuff I think most of the material now is ferrous free, but there is old material out there in people that is not ferrous free.

And there it has been catastrophic events of like pieces of metal moving.

So I know can y'all see this picture?

Okay.

This is about this is in my hospital.

This is an IV pump stuck to the bore of the scanner.

So we have all these processes.

We scan everything.

This is safe.

So this is the pump that holds medicine.

That's safe.

That's an MRI compatible pump.

This is not clearly not MRI compatible.

Right.

So we do all of our screening all of our stuff.

The pole makes it into the scanner.

Bam.

Right into the magnet.

Right.

The nurse I don't like.

She has adaptive capacity right.

And high reaction time.

Grab the kid off the table and like thank God nobody was hurt.

But this this is what happens still in real life.

So can we create a design where this doesn't happen?

We had another incidents where, they brought the patient.

So anesthesia attaches a patient to a ventilator.

And that ventilator is MRI safe, but it's not ferrous free.

There are still metal in the ventilator.

So over time, if you don't lock the machine, it will become projectile.

So they bring the patient in.

Somebody unlocks the vent, they push the vent to the side.

They do the scan, take the patient off the table.

It's like a Saturday.

Everybody goes home.

Monday morning they come in the vents in the back of the scanner because the person that unlocked it didn't relock it.

Right.

So can we create a design where you don't have to remind me as a human to lock and unlock my bench?

I think so, so we did a lot of work in MRI.

This is just one way to hopefully mitigate some risk.

And I put down a bunch of things that we changed.

But the biggest thing was we oriented the doors in relation to the medical gases, which is going to drive where you plug in your anesthesia machine.

So if you move your patient in on the opposite side of the room is where your vet is plugged into, you should not have to unlock that machine, and that should mitigate that risk from occurring again.

So that's how and the human is never going to be like, oh, they put the anesthesia machine and the medical gases over there.

So like I don't do something silly, like we're never going to think that way.

But you might be able to design that way and now you've mitigated risk.

We also spent a lot of time talking about like handedness and provide a workaround.

So clinicians you're going to find you're going to when you work with physicians or clinicians would be like why do you do it that way?

I love working with architects students because you guys see things that I will never see.

That is great.

Like I'm you remember you asked me like, why is your trashcans not on wheels?

And I was like, I mean, that is a great idea, right?

Like, and it's just some of those things that you just see the world through a different lens.

So clinicians are very, like muscle memory driven.

And so we always do things with the same hands.

If you put stuff on the wrong side of us, we're going to do this.

We're not going to like use.

We're not going to shift what hand we're using to do things.

We're literally going to cross our hands.

That's the silliest thing I've ever heard.

But it's the literal reality, right?

So if you start to lay out your room that makes people do things in a non ergonomic way, don't think that they're going to adjust to your environment.

They're not they're going to make adjustments in their own ergonomics.

Does that make sense without getting into like the nitty gritty details okay.

So just in the interest of time.

So getting it right is not easy.

So this is schematic design.

And you can see like initial design versus redesign and we like blew up some of these clinical areas.

So we and this is after like three meetings of schematic design where clinicians sat around a table and told the architects it's the design is fine.

And then they went into backups and they were like, this doesn't work at all.

Right.

So that's some of the limitations.

So I'll tell you that this is one way that that did design drives care okay.

So just to orient you to the space.

So here is a nurse server.

It's a it's a 90 degree angle.

See I don't even know angles.

Anyway you can access it from the hallway and you can access it from the patient room.

It's supposed to be great for nurses, right?

Because if you need gowns or meds or whatever or some supplies, you don't have to take your gown off.

Go outside, open a nurse server, go down the hallway, do whatever you can literally gain access to thing with things within your room.

Great, right?

Do you think there's any downstream consequences of that?

What might do you have any ideas of what they might be?

That's one of them.

Yep.

Which I'll tell you, we made some decisions around that.

And now my nurses think the doors are on backwards, so that's great.

But yes.

Exactly.

Right.

So it drives this design, drives human behavior.

Right.

So nurses are going to naturally orient their workflow to this side of the room.

Like why would they work over here.

Why would they plug their I.V.

poles in on this side of the room and then access their equipment over here?

They're not going to.

Right.

So when we got into, Sam, like the nurses and the therapists all wanted to plug all their equipment into the same side of the room, and we're like, I mean, you guys can't do that.

Like, first of all, there's not 100 outlets and one side of the head wall, and you can't have all your equipment over there, and they want you to be by the door because they can get to their equipment the fastest if they're next to the door.

So this room design really augmented how we were going to orient flow, but then to make sure the respiratory therapist stayed on the right side of the room, we actually disproportionately made medical gases on one side of the room.

So the therapist literally cannot orient their workflow to that side.

They actually hate it, but we knew that we had to make that kind of design change.

If we equally distribute our medical gases, everybody's equipment would be on the same side and it would be a disaster.

Right?

And so not only did the design drive workflow, but then we also made subsequent downstream decisions based on what we wanted the humans not to do in that space.

That makes sense.

Room design.

I mean, there's so much controversy over like single standard, mirrored, same handed, but there's nuances in how we deliver care and there's nuances in what equipment we use.

So when you have a room that's this complex and care that's this complex, you really have to start to unpack some of those nuances in how people are utilizing the space and what is the impact of that room design on, on what they're doing.

So like if you notice, you can kind of tell here, like, this is not how this room is intended to be used, right?

This is not in the foot wall to headwall orientation.

So the staff we turn the bed.

Why?

Because this space doesn't work for us, right?

We have to get access to the head of the bed.

And when you're in a head wall, when you're the patient bed is oriented to the correct head wall to foot wall position.

The least amount of space is at the head, right?

So now I've turned and rotated the entire room around so that I can get access to the patient's neck right?

So now I've 100% not used your design as you intended it.

The room shape doesn't support getting to the head of the bed either, because it's much it's a rectangle, right?

So it's much longer this way than it is wider.

Right?

I still don't know.

I would love to figure out the right design of ICU.

So if anybody's interested in that research project, just let me know.

Hallways can be much longer than, than what we imagine them to be.

And this has a whole big implication on how we utilize space.

So, Sam, so any questions before we get into SIM?

Okay.

So why use simulation and why use simulation based hospital design?

Testing is a little bit more than just walk through and simulation.

It's a rigorous methodology that applies evidence based design, patient safety theory, systems engineering work to really unpack some of these complexities and look at the design through a lens that focuses on patient safety.

And so it really elucidates those nuances in clinical care that your clinicians are not going to be able to explain to you around a table, and it really bridges that gap between work as you imagine it versus work as it's actually done.

So this is one of the, architects working on the project, doing CPR on a patient.

Right.

And, we kind of threw her into the mix because it gave her an opportunity to actually experience what it feels like as a clinician to be in this space, taking care of a really sick patient.

Right.

So not only do we get to see the design through her lens, but she gets to start to see the design through our lens.

So I didn't I'm not going to get into much to methodology, but I'm happy to give you and share tools with you.

But we use, a specific debriefing approach, because if you ask clinicians what they think of the space, they're going to talk about tasks and process, and you're going to say, that does not help me at all.

And so you really need to help them to see the the space through a lens that focuses on design and the built environment.

And then we use something called failure mode effect analysis because you're going to get a lot of feedback, and B, you're going to get a lot of, I like this and I don't like this.

This work is often being done 7 to 10 years before a hospital is actually open and functioning.

Right.

In this post Covid era.

Nobody is staying in healthcare for ten years anymore.

So the nurses that participated in Sam, like 70 to 80% of them are going to be gone.

So you don't want to build a hospital based on preferences and then those people aren't even there.

Right?

So, using patient safety theory and what we call failure mode, in effect analysis is a scoring rubric that gives an objective measure to what people are saying.

Like, you can't just say, I don't like the room in this way out.

You have to say, what is the risk?

What?

How is this going to harm your patient?

How is this going to impact your work efficiency?

How is this going to impact experience?

Or is this a regulatory violation.

And then it helps to kind of score and prioritize all of those things that you uncover.

The reality also is that we can't test everything.

Right?

So, you don't have there's not going to be time, there's not going to be space to mock every single area up.

So what do we do instead?

It's really important to be mindful about how you're asking questions so that when you sit down at a tabletop meeting, you're getting information that's going to be useful to you.

So as you think about a stacking diagram, it's really important to consider things like the relationship of your high acuity areas.

Where is your IQ in relation to your oers.

Where is your emergency department in relation to your imaging department?

How do people move through that space?

What program or departments need to have synergy and be built close to each other?

I'll tell you, like, our pick is on the eighth floor, like we're far from everything, right?

Like our areas that have the most amount of patients decompensated are not close to us.

Right.

So could we have stacked the building differently?

What is the path of travel and how complex is it to get around the building?

So you might ask, like what what areas do you move patients between often.

How does your code team work?

Where are they coming from and where they often going?

How does your patients move and what are some of the risks that you see with patients moving throughout your building?

And then there's schematic design.

So how is your space actually getting laid out?

The center for Health Design has a great like risk assessment toolkit.

It's really made for post occupancy or like when the building is already constructed.

But we have modified the the tool so that it is applicable to the built environment.

And I can send you guys these tools, but these are some of the questions that you want to ask.

Like was your layout efficient?

Was there distraction?

Did you have a lot of cross traffic?

Was there lack of privacy?

Did you have to walk a lot?

So and or these are some of the questions that you want to ask as opposed to like does this work for you?

Because they'll be like, sure.

Or they might give you an answer that it doesn't and then make you put the med room in a place that actually doesn't make any sense.

So you actually want to anchor them to, specific questions, similar things when you get into design development and really looking into the details of the space, you want to target your objectives and your questions to very specific things that you're asking for.

And this can help get you some more useful information.

When you're sitting around a table with clinicians, how much time we have?

Okay, let me skip.

Yes.

So I heard you guys are interested in technology.

Okay.

Who loves robots?

Seriously, I heard you guys are, like, really thinking about robotics, right?

Okay.

They are becoming the bane of my existence.

So I want to give you the clinical perspective of reality.

Robots are great, and so they ruin my life.

Okay, so I want to show you.

I wish we had sound, but.

So this is my team member getting in a fight with a robot, literally.

So they're big, they're cumbersome.

They are in my way all day long, okay?

All day, every day.

And I was like, you're going to break this thing, and then we're going to go to robot jail.

But, so this the you want technology to fix things.

You do not want it to create workflow disruptions and make our lives difficult.

And you have to shape the built environment to align how your technology is going to integrate with your humans and care delivery and your hospital operations.

So we spent a lot of money on these robots.

And we have three kinds.

We have one that delivers supplies, one that delivers medication and one that delivers food.

There is robots up and down my hallways all day long.

This video you can't hear, but they are very distressed.

So this robot is interrupting rounds.

So I don't know if you can tell, but what is everybody doing?

They're having to stop rounds back away from the hallway.

I asked them, how many times did a robot go through your rounds today?

They said they had.

The robot had already interrupted them four times, and I don't know if you can see the look on her face, but she's like over it.

By the end of the day, we're all over it, right?

And so the robots are cool.

It's interesting technology.

It's very expensive technology.

It is literally disrupting our workflow.

And so there might be built environment, things that you could do to augment that.

Right?

We have eight foot hallways.

The hallways are not big enough.

They're coming down the hallway.

So is there a way for them to only be back of house or off stage and not come into the, patient care areas?

Is there a way to operationalize them?

Like, can they just not come down the hallway during rounds?

Right.

So those are some of the realities, like I think technology is becoming is about to explode in health care if it hasn't already.

I think we're now saying like the future is now, but it has to integrate into what we do.

And we are slow adopters of technology, really slow.

We don't trust it, we don't adopt it.

We don't buy into it as health care clinicians because at the end of the day, like AI, the human and responsible for my patient, I am as the leader responsible for my staff.

And so for us to integrate these things is not so easy.

So as you think about integrating technology into your, designs, think about how is a human going to interact with this?

Does it move fast enough?

Do you see how slow at least I don't think oh, you can see how slow this thing is.

So first of all, if it's in my way, it's moving too slow.

It's super heavy for me to, like, stop and push out.

And if I need meds quickly, they're not coming up fast.

Right.

And so these are some of the realities of limitations.

Also they get in fights with each other because we as humans keep stopping them from coming down my busy hallway when I have stuff in the hallway that I need for my patient.

So they're stuck in a fire door, which my, an MEP person told me was not a good thing.

And I was like, I don't know anything about fire doors, but that's fine.

And then they're stuck in an elevator bank, right?

So now nothing is moving anywhere.

My supply cabinets are empty, my meds are late, the food hasn't been delivered for over two hours, and this is what we're dealing with.

Should we stop there and do questions to you?

You guys have questions?

Okay, let me stop there.

Let me just see.

Let me just one more thing about clinicians and our experiences.

So there's what we know we need, and then there's what we don't know we need.

And I never thought about access to light, nature anything until I started kind of talking about design.

I had gone I used to do 27, 30 hour calls.

There would be two weeks where I never saw the light of day.

And I was cranky and exhausted by the end of that.

Right.

And so there's things that we know that we need.

We know we need space to work.

We know we need space to collaborate.

We know we need private space to vent about how much we hate our job some days, and then what we don't know, we need we have no idea that we need access to nature.

We have no idea that we need access to daylight.

We don't know how design impacts our mood or our stress or anxiety, and we don't know how to take moments of respite.

This is our back of house.

So you can see, like, patient facing is like, colorful, has leaves.

This is what it looks like when I walk in and out of work every day.

Right.

It's kind of dreary.

And it's bland and there's no, there's not a lot of signage.

So how can we do things that are maybe cost efficient to kind of augment our experiences?

In the spaces in between?

And I will end there and open for questions if you.

Yeah.

This work.

Thank you.

Yeah.

Of course.

Thanks for covering the mock up for the pediatric ICU.

I actually got to visit the actual room, and the amount of effort that went into this was just.

Thank you.

Amazing work.

I, I can't wait to see the final results.

Oh, yeah.

Come on over.

Yeah, yeah.

Well, okay, let's see if there are any questions.

Answer.

Oh, so we're looking at, like the previous occupation programing.

Yeah.

Do a gaming matrix where you take your pieces and move it around.

And if you do do that part of that conversation, the nurses part of that or.

Yeah, that's a great question.

So it is a tool we did we call them paper doll exercises.

The problem with a lot of the end user groups is that you're, you have managers and above, and so you've got people that are overseeing a lot of things and are knowledgeable, but they have not necessarily been practicing at the bedside for maybe over ten, 15 years.

And so they give a lot of feedback that then the frontline staff come in and they're like, that's not how we do things.

Right.

And so that's a gap in the paper doll.

I think paper doll is one step like it's another step in engagement and fidelity from a 2D drawing.

But it still has quite a lot of limitations.

Now you can't.

It's much harder to mock up a programing or stacking diagram.

Right.

So, you're going to need to augment it with some of those types of exercises.

And so it's better than nothing because it gets people like up and engaged.

But always remember there is still a huge gap in between what their imagining and what is actually going to be a reality.

It's a great question.

Oh yeah, these nice.

Okay.

Any other questions?

Especially from the studio?

I know some of you guys are working on integrating robots into the surgical suite.

Okay.

And then what's your question?

All right.

So in our mock up with some of our designs, with integrated robots, we are looking at possibilities of robots utilizing a separate circulation route that connects to us.

I would say on stage, and that would not interrupt any staff circulation.

Have you seen concepts of that flying around?

So what are your thoughts on that?

Yeah, I think so there are some places that have done Avs that are all off stage.

And so for me, keeping that stuff off stage is going to be much better than intersecting into the flow.

If you're gonna intersect into the, into the if you're going to cross on stage and off stage, then it's really important to understand what does that space look like?

What can you fit through that space and understanding?

What is the flow?

What is the flow of traffic?

Who's moving?

What kinds of patients are moving where they're going?

Are they moving fast?

Are they moving slow?

Are there high risk situations happening?

Right.

Like if it is, so in your pre-op area, you've kind of got your, pre-op space into the O.R.

or into the pack you pack you into recovery.

Depending on if you do stage 2 or 3, or you combine those two so often, like your lower acuity situations, for the most part, are going to be pack you into your O.R..

Right?

So if you think about that path of travel or your robots crossing that, that's probably there's a lot of traffic there.

But maybe the acute acuity and urgency is lower versus if you're robots are past passing a path of traffic from the O.R.

to pack you, you really have to be mindful of, like, what that intersection looks like.

So I would say as much off stage as you can.

And but where they cross, be really mindful of those intermediate areas and what's happening in those spaces.

And you'll need to understand the clinicians workflow and what their O.R.

looks like.

Like what kind of patients are they taking care of?

How high acuity is that O.R., to kind of get those nuances that answer your question.

Yeah.

Thank you.

But there are, some buildings that are actually built so that the Avs just come up off stage and they dock and that's it.

You also it also impacts operations.

Right?

So if you're building robots so that so let me ask you instead of me answering the question and making assumptions, why are you putting robots in the space.

What problem are you fixing?

We are trying to make the circulating nurses job more efficient within the operating room.

So having to leave the operating room, the robot would get just transported materials to the operating room, so that outside of, as the circulating nurse said, go between the station scrub nurse and the that, robot location.

And that's just so we try to figure out in our simulation.

Yeah.

And that's great.

Right.

So you also, it's important to think about whose work are you offloading and where does still where does a human still need to offset that.

Right.

So based on the sterility of that robot and where they're going.

Right.

If they're going across this would be an infection control question.

But if they're crossing, like if they're so you have your red line, right?

Which is all sterile.

Right.

But then you've got your so if your case is going, you have only one way of entry in.

Right?

Everybody's going to come in the clean core because that's the cleanest air flow.

So correct me if I'm wrong.

That's the cleanest air flow space.

Right.

So if your robot is circulating and bringing in supplies, are they crossing a path that's not that's less sterile or are they always coming in and out of the clean core so they can they come into the O.R.?

Or does your nurse still have to go out into the core to pick up what's off the robot?

And that's just like a small example, but those are some of the nuances that you're like, how much does my staff actually still have to do?

So for us, the robots still have to be emptied by a human right.

So and this ICU workflow is very different than our workflow.

But the pharmacy cart comes upstairs and it says we have medications and it sends like 1000 volt messages or something to people that are nowhere around it.

And if the nurse is in another room doing something, they're not going to empty the pharmacy cart.

So the so the robot leaves.

What happens to the meds?

I have no idea.

But like they're not getting delivered.

Right.

And so like those are the kinds of things that as you build the infrastructure and you build the integration of robotics, those are some of the nuances that simulation will help you uncover those gaps.

Can the nurse, is that actually going to work for the nurse workflow, like if it lands in the in the, door to the clean core, can she is it going to be efficient for her to go open it, or is there another person that might need to be assigned that task, or does it actually not offset her workflow at all because maybe she's busy doing something else?

The other thing is, how fast is it getting this stuff right?

So what does she have to do to tell a robot that she needs a piece of equipment?

And then is it going to find it quick enough when the surgeon dropped the needle or dropped something on the floor and is screaming like, I need my blah blah blah, like, is it going to be faster than her?

Because the reality is, is if it's slower, she's still going to get it herself.

Right?

And so like, what kind of what are you utilizing the robot for?

Is it like we need to set up this room.

So you're just going to we're going to have the robot bring everything.

But then if there's a urgently needed supplies, the nurse is still going to go get it.

Do those kinds of nuances.

Does that make sense?

Did I rain on your parade?

Yeah.

Oh, gosh.

I think they're millions I don't yeah the system.

So the system for.

Yeah the system infrastructure is extraordinarily expensive because all the floors have to be mapped, so that the robots can be on a pathway.

So you have to build it into the building.

The later you build it into the building, the more expensive it is.

So if you decide to do it past the point of like CDs, you're if your cost is going up exponentially to and then now you've built a building that may not accommodate robots, right?

Like your hallways might not be big enough, your elevator banks might not be big enough, or your, you know, your elevate, your doorways might not be big enough.

All of that, but you're you're looking in the like millions range.

Yeah.

It's a great question.

It's not cheap for sure.

Yeah.

It's the great questions.

All right.

So thank you.

Yeah for joining us.

And this is something really small.

For you.

Oh thank you.

Thanks.

Happy to be here.

Yes.

Is it right.

Right.

Like I bought.