You don't know what you don't know until you know it.
That's the lesson leaders at ProMedica Toledo Hospital in Ohio learned during the design of its 615,000 square-foot patient tower set to 2019.
As part of the design process, the organization took part in research to identify and refine ways to improve nursing care and efficiencies, including distance traveled during a shift.
Architects from HKS, Inc., the firm designing the building, approached Alison Avendt, OT, MBA, vice president of operations, at ProMedica Toledo Hospital about doing the research.
"We have a building that we opened in 2008, so they wanted to look at how we were using the spaces [there], and get feedback from nursing on how it was working," Avendt says.
"That was really attractive to me because I heard we had issues with the building that we were in and there were many things that we wish we could have done better. I thought if we could do a good design diagnostic and learn something from that, it would really help guide our design work."
An Applesauce Moment
During two days of onsite observation, researchers shadowed ICU nurses and intermediate-level medical-surgical nurses. The researchers assessed the existing floor plan, used a parametric modeling tool, and created heat maps to provide a graphic representation of what a nurse's 12-hour shift looked like in terms of workflow and walking distances.
"One of the big [revelations] was around our whole process of medication passing," says Deana Sievert, RN, MSN, metro regional chief nursing officer and vice president for patient care services at ProMedica.
Observation revealed that a nurse reviewed the patient's medication administration record in the patient's room, walked to the supply room to get the medication from the Pyxis machine, and then often had to stop by the patient refrigerator to get something—like applesauce—to aid in the medication pass before walking back to the patient's room to administer the medication.
"It was something that was just so ingrained in our staff nurses' normal daily activities," Sievert says. "When they did the heat mapping it was like…'Wow. [There's a] big pinch point that we as staff nurses didn't really even realize was there.' "
Avendt says the researcher called this realization "the applesauce moment."
"Nurses are masterful at just making things work. There are a lot of things that the nurses knew were not value-added or were problematic, but they would just make it work," she says.
"It was really good to flesh out what those things were by observing because if you just ask[ed] them, the nurse would often not be able to verbalize what the problem was. But by seeing it, it came to light."
The architects used this information to design a unit that would cut down on walking time. Instead of a long corridor with a common area at one end, the unit was broken up into pods and supplies were located in multiple areas so nurses could get them from the location to which they were closest.
"We were able to take them from a three-mile journey on their shift to 1.5 miles. We cut in half the steps that they were taking," Avendt says.
After the tower opens, more research will be done to see how the design is affecting workflow.
"We've since learned that [field research] is not common for people to do. We paid a little bit of money to do that, but in the scheme of things it was well worth the investment," Avendt says.
"Everybody wants to give the nurse as much time as possible to be with the patient [and] try to take away the things that are not value-added in the nurse's day."