The author ... Joe Flower is an internationally known futurist and consultant to health care executives. This represents his posting of 1/24/12 in H&HN Daily. I highly recommend this article by him to all of my students.
REH
Better Ways of Thinking about the Future
By Joe Flower January 24, 2012
How do you learn to "Think Different," as Steve Jobs' famous ads put it?
Let's think about the structure of thought for a moment. The great experimental psychologist Daniel Kahneman, in his recent book Thinking, Fast and Slow, shows how much of our thinking and decision-making is driven by illusions and assumptions, such as the "illusion of validity" (the false belief in the reliability of our own judgment), the "availability bias" (a biased judgment based on memories that are more easily available or more vivid) and the "endowment effect" (the tendency to value something more highly when we own it than when someone else owns it).
This makes sense. Kahneman's analysis resonates strongly with my experience working with executive health care teams, including providers, health plans and suppliers, and with governments in North America, Europe and China over several decades. Smart, seasoned executives can make seriously poor judgments, especially when the environment changes.
Curiously, these illusions, biases and assumptions are driven by our experiences. So, being more experienced does not necessarily exempt us from illusion, unless something in our process constantly and directly tests the results of our judgments (as, say, a robust retail market does on price setting). Even if the judgments are correct, they are based on an environment: in the jungle or the savanna, in a controlled market or a retail market, in a risk-bearing business arrangement or an endowed business arrangement. When our environment shifts, the illusions and biases and assumptions persist, even though they may be dangerously out of date.
We are in a rapidly shifting environment. Over the next several years, all health care leaders will be called on to make numerous strategic decisions and tactical choices that fundamentally will be different from decisions they are used to making. But they will be making those decisions with a mental apparatus formed in the old environment.
A Thought Exercise
How do we rethink our assumptions? How do we approach the unfolding situation with a continually fresh mind?
Here is a basic and enormously useful thought exercise. Take some time to write down a number of basic facts and beliefs about your organization, anything from facts such as "We own XYZ Home Care" to opinions such as "Tom's a lousy communicator." Then take one of these "truths" and find several ways to form an opposite of it.
An opposite of "We own XYZ Home Care" could be "We don't own XYZ Home Care," "Our crosstown rivals own XYZ Home Care," "XYZ Home Care owns us," or "We keep XYZ Home Care's assets, but farm out the management," or even "The business we now think of as 'home care' disappears and becomes something else," for instance.
The opposite of the opinion "Tom's a lousy communicator" could be "Tom's a great communicator," "I'm a lousy listener to Tom," or "There's really no need for Tom to be a great communicator."
Entertain one or another of these opposite assumptions for a while. Treat it as if it were true. Assume that, in some way, it actually is true or could be true. How does that feel? In what ways might it actually feel true? What would be the consequences if it were true? Explore it; give it room to grow.
This is not a test of your original assumption, but a way to ferret out different assumptions and give them room to play in your judgment. Your original assumption may be correct, or it may be correct for now, or it may be as correct as some of its opposites. Maybe Tom really is a lousy communicator, but you're also not so good at hearing what Tom is on about, and in Tom's job it's not so important that he be a good communicator. In making your assumptions explicit and overturning them, you can find other truths — and in a deeply shifting strategic environment, we will need to find lots of new truths.
Overturn Assumptions
In this year of thinking dangerously, here are some assumptions to entertain that may be counter to the way you are thinking now. Try them on for your organization and your environment. See if the act of taking them, experimentally, as true turns up other thoughts that might add to the power of your judgment in the changing environment.
Assume brevity. Assume that your current product lines, business models, revenue streams and business structures have a short half-life — that they are not permanent but will disappear. Many businesses (such as consumer electronics) have this assumption built into their DNA. In health care, we make the opposite assumption: If we have a cancer program, if we make our margin on the employer side, if the sleep center is a good revenue stream, we assume permanence until proven otherwise. Assume brevity — actively search for, create and incubate alternatives.
Assume common ground. Assume that your business adversaries and rivals can be allies. The health plans, your crosstown rivals, or the city government may be making life difficult for you now. But under different business assumptions, for particular product lines, revenue streams or business structures, your strongest rivals may be your natural affiliates.
Assume all form is classical. If you are thinking of some new business direction, something that seems radically new to you, assume that somebody somewhere is already doing things this new way, is doing it well, and has learned something about how to do it. Assume that, rather than start from scratch, you can beg, borrow, pirate, buy or copy their expertise and experience — and then improve on it.
Assume new capacities. Assume that your organization does not have the capacities that it will need in its evolving environment.
Assume new abilities. Assume that your organization has latent abilities to learn, change and create that you have never tapped; that it is possible to tap them; and that you could learn how from other organizations.
Assume heterodoxy. Assume that there is no one right way to do health care, even for you to do health care in your market with your organization, but that there are many partially right ways.
Assume exotic provenance. Assume that the answers are not all in health care. As the business environment changes, we will increasingly find that we can learn things from other industries, that other industries represent a "target-rich environment" for new business ideas, revenue streams and risk structures that we can use in our organizations.
Assume the fruitfulness of challenge. Assume that a leader's most important task is to pose the unanswerable questions, the true challenges, to subordinates. Any question that actually has an answer is a technical question, not a leadership question. Leadership deals with the unanswerable, with where we could be and where we might go. Being the smartest person in the room and having the right answer is the smallest part of the job — and can actually get in the way of finding the best answer and the greatest intelligence the organization can manifest.
Assume curiosity. Curiosity is much more valuable than answers. Questions are far more useful than fixed opinions. Foster curiosity in your subordinates, in your customers, in your allies and potential allies. An organization displays and feeds curiosity by starting pilot programs, fostering new product lines, seeking out new allies and relationships, then seeing what works and pruning the rest.
Assume ruthlessness. Don't fall in love with what you create. It's a new environment. You have to try new things — and you have to kill off what does not work.
Assume competition. Assume that in a changing business environment, if an opportunity shows up, someone will take it. It could be you or it could be a competitor. The opportunity could be something not yet invented in your market, or it could be something you already do that someone else finds a way to do better, faster or cheaper.
Assume the bottom of the pyramid. Assume that there are opportunities on the low end, that there are ways to find margin even serving the least well-insured and the least well-employed. The reason is simple: The changes in the health care business environment likely will increase, rather than decrease, your exposure to the low end of the market, and will decrease the ways that you can offset losses in serving it. You have to find margin, and you will not find it if you assume it is not there.
Assume ignorance. Assume that you do not know enough about your own organization and its environment to make the best decisions: how much particular processes cost you, which of those costs are flexible, which are even unnecessary, where your revenue streams actually come from, who the true decision-makers are, both in incurring costs and in becoming customers. "Big data," the ability to drill down into the masses of information your organization produces and come up with answers to such questions, could be your friend.
Assume decision-making from ignorance. Assume that you will never really know enough, and you will have to make big decisions anyway.
Assume that it's always a decision. Assume that to make no decision, or to delay a decision, is itself a decision.
These are a few examples of the ways we must continually overturn and test our thinking, expose our illusions and bring a fresh mind to our strategic judgments. No matter how smart or how experienced, the mind whose expertise was formed in business models of the past decades is ill-equipped to make judgments in the Next Health Care as it forms and re-forms over the coming several years. When the mind of the leader learns to change first, then the organization can learn and change.
Joe Flower is a health care futurist and CEO of The Change Project Inc., and its health care education arm, Imagine What If. He is also a regular contributor to H&HN Daily and a member of Speakers Express. His new book,Healthcare Beyond Reform: Doing It Right for Half the Cost, will be published in March 2012 by Taylor and Francis.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
Tuesday, January 24, 2012
Friday, November 4, 2011
"Learning Health Systems"
News release 11/4/11
IOM reports on efforts to develop a ‘learning health system’
The Institute of Medicine recently issued a report on efforts by its Roundtable on Value & Science-Driven Health Care to promote a “learning health system.” Guided by leaders from key stakeholder sectors, the Roundtable has worked since 2006 to accelerate the production and use of needed evidence on what works best in health care; characterize and explore the nature, potential and elements of a “learning health system” that yields continuous improvement in outcomes while reducing the costs of health and health care; and marshal collaborative action. The report summarizes a series of Roundtable publications that present a vision and strategies for a learning health system, and efforts by its Innovation Collaboratives to accelerate progress in five areas: best clinician practices, innovative effectiveness research, digital learning, evidence communication, and value incentives. Roundtable members include AHA Trustee Jonathan Perlin, M.D., president of clinical and physician services for HCA Inc., as well as other hospital leaders. For more on the initiative, visit www.iom.edu/vsrt.
IOM reports on efforts to develop a ‘learning health system’
The Institute of Medicine recently issued a report on efforts by its Roundtable on Value & Science-Driven Health Care to promote a “learning health system.” Guided by leaders from key stakeholder sectors, the Roundtable has worked since 2006 to accelerate the production and use of needed evidence on what works best in health care; characterize and explore the nature, potential and elements of a “learning health system” that yields continuous improvement in outcomes while reducing the costs of health and health care; and marshal collaborative action. The report summarizes a series of Roundtable publications that present a vision and strategies for a learning health system, and efforts by its Innovation Collaboratives to accelerate progress in five areas: best clinician practices, innovative effectiveness research, digital learning, evidence communication, and value incentives. Roundtable members include AHA Trustee Jonathan Perlin, M.D., president of clinical and physician services for HCA Inc., as well as other hospital leaders. For more on the initiative, visit www.iom.edu/vsrt.
Thursday, September 22, 2011
Are You Talking To Me?
Complete recognition is extended to Matthew Weinstock for his article, published September 22, 2011 in HH&N. Matthew Weinstock is the Senior Editor of Hospitals & Health Networks magazine.
Are You Talking to Me?
By Matthew Weinstock September 22, 2011
Better patient-physician communication is central to improving quality of care.
Since 2004, Bill Lee has had 10 heart attacks. That's not a typo: 10 heart attacks in 7 years.
He has coronary artery disease. Oh, and he's diabetic.
A few years ago, he was lying in a hospital bed after his seventh heart attack and his doctors told him, "There's nothing else we can do for you. You are just going to keep having heart attacks."
"That's not acceptable to me," he said. "I'm not going to accept your diagnosis and your prognosis."
From that moment, Lee took it upon himself to become an informed patient. He researched his conditions. He made a list of questions before every doctor's appointment and, importantly, he asked them. That was a new behavior for Lee. He used to be like so many of us, just accepting what the doctor said and taking his medicine, no questions asked.
Lee's compelling story is featured on a new website, "Questions are the Answer." Developed in partnership between the Agency for Healthcare Research and Quality and the Ad Council, the site is aimed at providers and patients, encouraging them to become more engaged in two-way communication.
"We know that when patients and clinicians communicate well, care is better. But in today's fast-paced health care system, good communication isn't always the norm," AHRQ Director Carolyn Clancy said in a statement. "This campaign reminds us all that effective communication between patients and their health care team is important and that it is possible — even when time is limited."
The AHRQ site, unveiled on Tuesday, contains a host of tools including one that lets patients create and prioritize a list of questions. Hospitals wanting to do a better job of promoting two-way communication can co-brand materials from the site.
Matthew and Carolyn Bucksbaum, meanwhile, are putting up $42 million to ensure that their home hospital, the University of Chicago Medical Center, bolsters doctor-patient communication. Matthew Bucksbaum is CEO of shopping mall behemoth General Growth Properties. The Bucksbaum Institute will "train medical students and faculty who, in turn, can serve as role models in communication and shared decision-making."
Of course, it is one thing to put up millions in the hopes that folks adopt shared decision-making, it's entirely another for that to become a reality. The National Institute for Health Care Reform on Tuesday issued a very insightful report detailing the many barriers to shared decision-making. The report, authored by researchers at the Center for Studying Health System Change and Mathematica Policy Research, also offers an array of policy solutions.
Shared decision making is slightly different from two-way communication. The latter can — should, I would argue — be used in any situation. Shared decision-making is typically used for "common health problems" for which there is more than one "medically acceptable treatment option," according to the NIHCR report. The idea is that an informed patient will work with his or her doctor to choose the best care for their particular case.
The authors note, however, that there are many roadblocks: an arcane payment system, clinicians poorly trained in the art of shared decision-making, malpractice concerns, low health literacy among patients, and, not insignificantly, "political hyperbole" that "can stifle discussion and support for shared decision-making." Think back to the arguments on end-of-life care during the health reform debate.
The report, however, points out that both the health reform and stimulus laws elevate shared decision-making through the promotion of patient-centered medical homes, the creation of the Patient-Centered Outcomes Research Institute and more.
But the authors suggest that we need not wait around for elements of those laws to take hold. No, there are some real solutions that could advance shared decision-making right now:
Reward providers. While providers wait for a shift from fee for service, CPT codes could be revised to pay for shared decision-making activity.
Do a better job of promoting and teaching the concept in medical school and create some continuing medical education programs.
Address liability concerns. In Washington, for instance, there are legal protections for physicians who engage in shared decision-making.
Provide patients with more tools/aids.
Tap into the power of electronic health and personal health records.
The shift to accountable care, the medical home, whatever catch phrase you want to use, hinges on the patient (and family) becoming an active participant in the care process. I know this all too well right now. I have a family member undergoing intense treatment for Stage 3 esophageal cancer. He is not a very good patient advocate, but his daughters are and they accompany him to every doctor's appointment armed with questions. Thankfully, his physicians are welcoming of their input and are fully engaged in a dialogue about his treatment plan. Can you say the same about your doctors?
I welcome your thoughts. Email me at mweinstock@healthforum.com.
Matthew Weinstock is the Senior Editor of Hospitals & Health Networks magazine.
Are You Talking to Me?
By Matthew Weinstock September 22, 2011
Better patient-physician communication is central to improving quality of care.
Since 2004, Bill Lee has had 10 heart attacks. That's not a typo: 10 heart attacks in 7 years.
He has coronary artery disease. Oh, and he's diabetic.
A few years ago, he was lying in a hospital bed after his seventh heart attack and his doctors told him, "There's nothing else we can do for you. You are just going to keep having heart attacks."
"That's not acceptable to me," he said. "I'm not going to accept your diagnosis and your prognosis."
From that moment, Lee took it upon himself to become an informed patient. He researched his conditions. He made a list of questions before every doctor's appointment and, importantly, he asked them. That was a new behavior for Lee. He used to be like so many of us, just accepting what the doctor said and taking his medicine, no questions asked.
Lee's compelling story is featured on a new website, "Questions are the Answer." Developed in partnership between the Agency for Healthcare Research and Quality and the Ad Council, the site is aimed at providers and patients, encouraging them to become more engaged in two-way communication.
"We know that when patients and clinicians communicate well, care is better. But in today's fast-paced health care system, good communication isn't always the norm," AHRQ Director Carolyn Clancy said in a statement. "This campaign reminds us all that effective communication between patients and their health care team is important and that it is possible — even when time is limited."
The AHRQ site, unveiled on Tuesday, contains a host of tools including one that lets patients create and prioritize a list of questions. Hospitals wanting to do a better job of promoting two-way communication can co-brand materials from the site.
Matthew and Carolyn Bucksbaum, meanwhile, are putting up $42 million to ensure that their home hospital, the University of Chicago Medical Center, bolsters doctor-patient communication. Matthew Bucksbaum is CEO of shopping mall behemoth General Growth Properties. The Bucksbaum Institute will "train medical students and faculty who, in turn, can serve as role models in communication and shared decision-making."
Of course, it is one thing to put up millions in the hopes that folks adopt shared decision-making, it's entirely another for that to become a reality. The National Institute for Health Care Reform on Tuesday issued a very insightful report detailing the many barriers to shared decision-making. The report, authored by researchers at the Center for Studying Health System Change and Mathematica Policy Research, also offers an array of policy solutions.
Shared decision making is slightly different from two-way communication. The latter can — should, I would argue — be used in any situation. Shared decision-making is typically used for "common health problems" for which there is more than one "medically acceptable treatment option," according to the NIHCR report. The idea is that an informed patient will work with his or her doctor to choose the best care for their particular case.
The authors note, however, that there are many roadblocks: an arcane payment system, clinicians poorly trained in the art of shared decision-making, malpractice concerns, low health literacy among patients, and, not insignificantly, "political hyperbole" that "can stifle discussion and support for shared decision-making." Think back to the arguments on end-of-life care during the health reform debate.
The report, however, points out that both the health reform and stimulus laws elevate shared decision-making through the promotion of patient-centered medical homes, the creation of the Patient-Centered Outcomes Research Institute and more.
But the authors suggest that we need not wait around for elements of those laws to take hold. No, there are some real solutions that could advance shared decision-making right now:
Reward providers. While providers wait for a shift from fee for service, CPT codes could be revised to pay for shared decision-making activity.
Do a better job of promoting and teaching the concept in medical school and create some continuing medical education programs.
Address liability concerns. In Washington, for instance, there are legal protections for physicians who engage in shared decision-making.
Provide patients with more tools/aids.
Tap into the power of electronic health and personal health records.
The shift to accountable care, the medical home, whatever catch phrase you want to use, hinges on the patient (and family) becoming an active participant in the care process. I know this all too well right now. I have a family member undergoing intense treatment for Stage 3 esophageal cancer. He is not a very good patient advocate, but his daughters are and they accompany him to every doctor's appointment armed with questions. Thankfully, his physicians are welcoming of their input and are fully engaged in a dialogue about his treatment plan. Can you say the same about your doctors?
I welcome your thoughts. Email me at mweinstock@healthforum.com.
Matthew Weinstock is the Senior Editor of Hospitals & Health Networks magazine.
Friday, August 26, 2011
Designing space for the high-tech patient room
With complete credit for authorship to John J. Skreenock, HEM as published in the August, 2011 issue of "HEALTH FACILITIES MANGEMENT"
Designing space for the high-tech patient room
By John J. Skreenock, HEM
When planning for new patient rooms, today's health facility professionals have quite the challenge. They must ensure that the room design will provide effective, state-of-the-art technology when the space is initially occupied and adapt to future technologies.
This is easier said than done. Depending on the size of the project and funding, it may be years before the space is actually constructed and ready for occupancy. Working closely with a knowledgeable medical-equipment planner will increase the probability that the design will last well into the future.
Three types of rooms
Most hospitals have three general types of patient rooms, depending on the acuity level of the patient: intensive care unit (ICU) rooms, step-down or intermediate care rooms, and acute care rooms.
ICU rooms are grouped together in a unit to take advantage of the nursing skills required to care for these patients. These nursing units are called medical ICUs, surgical ICUs, cardiovascular ICUs and cardiac ICUs, to name a few.
Each type of patient room must accommodate an extensive array of specialized medical equipment required to care for the clinical needs of the specific patient population. Consideration also must be given to the safe and efficient use of fixed and movable medical equipment brought in to care for the patient. They also must accommodate nursing staff and the cardiac resuscitation team, if they are needed. Consequently, these rooms need to be designed to allow safe, easy access to all sides of the patient.
Once the types of equipment that could be used in the room and the location and position of the patient are known, the room layout can begin.
Room organization
A major consideration for an ICU room is getting the utilities to all the movable and portable equipment brought in and out of the room during a patient's stay. The ceiling, wall and floor space are usually at a premium in these rooms and the anticipated use of specific medical equipment will dictate the location of both the fixed and mobile medical equipment.
Types of utilities and outlets that typically need to be available in the room range from electrical and emergency power receptacles for equipment (e.g., ventilators, hemodialysis units and physiologic monitors); to low-voltage connections for various devices (e.g., television, information technology data lines for bedside physiologic monitors, electronic medical records and alarm monitoring); and medical gases (e.g., oxygen and medical air and vacuum outlets).
There are several methods of getting the utilities near the patient. Fixed floor-to-ceiling columns and movable ceiling- or wall-mounted booms have been gaining popularity over a standard prefabricated headwall or mounting the utilities directly on the walls adjacent to the patient bed. The columns provide better organization of the devices, better accessibility for staff and reduced wire and tube clutter, and fewer tripping hazards.
The columns and booms also allow for some bed movement to take advantage of window vistas, which have been attributed to patient well-being. However, window views may not always be an option due to existing external obstructions. One innovative hospital solved that dilemma by planning to install windowlike frames to display real-time camera views from several locations on the hospital roof.
If a fixed column or boom is used, space on the ceiling needs to be evaluated for proper layout, ceiling support structure and lighting requirements. Some ICU rooms may be equipped with one or two special procedural lights mounted in the ceiling above the patient for procedures that could be performed in the room in an emergency. Procedure lights sometimes are specified for ICU rooms. One model enables lights to be directed to the specific site using a wand- or wall-mounted panel.
Another consideration competing for ceiling space is the patient lift. Patient lifts can be mounted to the ceiling, installed as freestanding structures, or attached to a boom. The Facility Guidelines Institute's 2010 Guidelines for Design and Construction of Health Care Facilities identifies the need to conduct a patient handling and movement assessment and to address this during the construction process, which could have major implications for room design.
If there is a possibility of installing ceiling-mounted lifts in the future it is prudent to plan for them in the early design stages to prevent clashes with structures above the ceiling or to add structural support while the room is being planned.
Nursing staff need good visibility to the patient from the hallway. This is accomplished by using a significant amount of glass. However, sometimes privacy is needed for the patient and switchable or so-called "smart" glass is used in some units to accommodate the dual needs of privacy and observation.
With the touch of a switch, the glass changes from transparent to opaque, blocking light and providing privacy and security. This high-tech glass eliminates the need for blinds or curtains that may present an infection control risk and pose a cleaning challenge for environmental services. These glass panels are relatively expensive compared with that of standard glass, however.
Equipment needs
This is Modular Services Company's equipment solution for neonatal intensive care operations. The design team must ensure that the room is future-proofed for all of the equipment that may be fixed or wheeled into the room. It needs to consider the possible uses of the room when it is completed as well as how the room may be used in the future.
Ultimately, the type of critical care unit and patient determines which technologies are needed in the room. Most ICU rooms include ventilators; physiologic monitors mounted on a wall, boom or column; IV poles that are movable or mounted to a column or boom that can accommodate multiple IV pumps; and patient-controlled analgesia pumps. All of these may require multiple emergency-power receptacles.
Many of these devices will be integrated with the hospital electronic records through wireless connections. This integration requires that the information technology (IT) group be intimately involved with the planning of the room design and antenna placement.
Some facilities monitor ICU patients from a remote site, often called the electronic ICU or command center. For remote-monitored rooms, a pan-tilt-zoom (PTZ) camera, microphone and speakers — either ceiling- or wall-mounted — are needed to enable the remote site to communicate with the patient or nursing staff and observe patient and vital equipment displays and settings.
There is also a telepresence robot on the market that can be maneuvered into the room to gather the same type of information. This type of device requires a clear floor path through the room without wires, tubes or cables on the floor.
Intelligent patient beds are another new component in high-tech patient rooms. They not only require electrical power, but also a low-voltage data jack to connect to the hospital infrastructure for nurse-call and bed-exit alarms to monitor for fall risks. They also require connections for electronic medical records.
The flow of patient care within the room needs to be planned carefully to accommodate wireless workstations on wheels (WOWs), which typically are used for patient charting and confirmation of medication delivery. While they do not require an electrical receptacle or data jack, they take up space and need to be considered in the room layout. The typical footprint for the WOW is approximately 26 inches wide by 28 inches deep; however, newer tablet devices eventually may supersede WOWs for charting patient care.
As more and more new technology is introduced for patient care, the design team faces new challenges in providing the required utilities and adequate footprint. For example, ICU patients too ill to be moved for imaging studies need space in their rooms to accommodate mobile imaging devices like a mobile C-arm radiography or fluoroscopy unit.
The type of patient receiving care will dictate the equipment and utility requirements for the room. Here are some examples of typical ICU room equipment that have relatively large footprints and their utility requirements:
Hemodialysis equipment using continuous renal replacement therapy requires a hot and cold mixed water supply, drain and emergency power.
Ventilators require emergency electrical power, a medical air connection and a data connection for alarm management.
Hypo/hyperthermia units require electrical power.
Intra-aortic balloon pumps used in the cardiovascular ICU require emergency electrical power.
Video endoscopy carts or bronchoscopy carts require electrical power.
C-arms require electrical power.
Space also is required to ensure quick patient access by the resuscitation team with their resuscitation cart or crash cart.
Other types of ICU rooms may require very different equipment needs. For example, specialized orthopedic beds in a trauma ICU that provides for traction are usually larger and have bars that extend toward the ceiling. These require clear space above the bed to accommodate the bars. Likewise, neurologic intensive care areas may call for specialized monitoring equipment that require data jacks as well as a ceiling- or wall-mounted PTZ camera and microphone and speakers.
Point-of-care technology may have an impact on additional requirements for the design of the room as blood gas monitoring and portable ultrasound are becoming more prevalent. The key is using the medical-equipment planner to provide those glimpses into the technologies of the future of patient care and to raise the awareness of potential implications of the design on future needs.
Decisions must be made about making the investment to provide for the necessary flexibility, or at least addressing the potential impact, and designing the room to be able to add future equipment or technologies.
Beyond the ICU
Critical care areas aren't the only sections of hospitals with high-tech patient rooms. Step-down rooms and acute care rooms have their share of technologies requiring planning and installation considerations.
Step-down rooms are associated with the ICUs and have a reduced complement of equipment needs depending on the type of step-down unit. These rooms may be monitored via a telemetry transmitter that sends a patient's heart trace signals and maybe pulse oximetry to a central monitor that is being watched by a trained monitor technician. A step-down room also has a lesser requirement for both the regular and emergency electrical power systems and the number of oxygen, medical air and vacuum outlets. The design may have to accommodate fixed-ceiling patient lifts.
The acute care room has an even smaller complement of medical equipment and, consequently, less infrastructure. Some health care facilities are designing step-down and acute care rooms to be more like hotel rooms, conveying a less clinical and more comforting experience for both patients and their visiting family and friends.
Many hospitals also treat critically ill infants and children. Neonatal and pediatric ICUs have highly specialized equipment and unique room design requirements.
More of these rooms are being designed as private rooms to provide better control over the sensory environment for the neonate. Alarm management from the equipment in the room requires data jacks. Lines of site that are lost due to privacy and communication challenges need to be addressed with technology because of hard walls. Equipment to care for the neonate can be mounted on the wall or suspended from the ceiling on a boom. Utilities like regular and emergency electrical power are needed in sufficient quantity. Additionally, medical air, oxygen and vacuum are required, as are data jacks for connection to the central monitoring and the hospital information systems.
Planning for future
While considering the equipment now used in each type of room, hospital designers and facility managers must work in conjunction with clinicians to consider the potential use of the room in the future.
It is generally easier and less expensive to include additional space, electrical and data outlets, and utilities while in the design and construction phase of a project, rather than waiting until the spaces are occupied with patients and then deciding an upgrade is needed.
John J. Skreenock, HEM, is senior associate for the Applied Solutions Group at ECRI Institute, Plymouth Meeting, Pa. He can be reached at jskreenock@ecri.org.
Sidebar - Flexible rooms provide savings
A medium-sized hospital planned to renovate a couple of its acute- care nursing floors and convert all of the semiprivate rooms to private rooms, creating a new intensive care unit (ICU) step-down space.
While initial plans called for the rooms to be used for step-down patients, the longer range plan was to convert these spaces to ICU rooms when needed. For a step-down room, telemetry monitoring is sufficient. However, for future use as an ICU setting, centrally monitored, wall-mounted physiologic monitors or other high-technology equipment would be required.
With that in mind, the design had to be modified. The hospital decided to plan the rooms with increased infrastructure to handle the future conversion. Increased gas and vacuum capacity for additional outlets and additional electrical power and data jacks allowed for future upgrades.
These design changes now allow the high-technology equipment that is routinely deployed in the ICU to be used in these rooms in the future. The cost for such infrastructure at such an early stage is a fraction of the cost required in the future to convert the rooms.
However, cost is only one factor that would be considered for future conversion. If the hospital had not increased the infrastructure during the original renovation, a future conversion would have faced major complications, including the potential loss of revenue while the rooms were being renovated extensively, disruption to patient care and department operations, complex infection-control issues and a longer time to complete the conversion.
With all of these considerations, the conversion for ICU patients may never have happened.
Sidebar - Prepping for mass patient surges
When hospitals need extra space for unplanned patients in mass numbers, such as during or after a flu epidemic or a disaster with mass casualties, some facilities provide a flexible solution for allowing the census in a particular nursing department to flex up in times of need and then flex back down when the need subsides.
A portion of the acute care private rooms are designed with the ability to accommodate two patients in the same room, essentially creating a semiprivate room. This flexibility is provided by having the room designed with built-in infrastructure, such as utilities to accommodate two beds.
The design requires two headwall arrangements, each with enough gas and vacuum outlets; regular and emergency power; data jacks for plugging in equipment that communicates with the hospital's information systems; and separate lighting controls for each bed. Movable equipment required for patient care, like beds and IV pumps on poles, can be wheeled in when needed.
The second bed can be set up similar to the first but may not need all the amenities, because it only would be used for a short duration. Flexibility designed into the rooms allows for an unexpected short uptick in the hospital census.
The surge plan then will call for fixed medical equipment as well as additional mobile medical equipment to provide patient care. The mobile equipment may be relocated from another area of the facility, from storage or requisitioned from local rental firms.
This article first appeared in the August 2011 issue of HFM magazine.
Designing space for the high-tech patient room
By John J. Skreenock, HEM
When planning for new patient rooms, today's health facility professionals have quite the challenge. They must ensure that the room design will provide effective, state-of-the-art technology when the space is initially occupied and adapt to future technologies.
This is easier said than done. Depending on the size of the project and funding, it may be years before the space is actually constructed and ready for occupancy. Working closely with a knowledgeable medical-equipment planner will increase the probability that the design will last well into the future.
Three types of rooms
Most hospitals have three general types of patient rooms, depending on the acuity level of the patient: intensive care unit (ICU) rooms, step-down or intermediate care rooms, and acute care rooms.
ICU rooms are grouped together in a unit to take advantage of the nursing skills required to care for these patients. These nursing units are called medical ICUs, surgical ICUs, cardiovascular ICUs and cardiac ICUs, to name a few.
Each type of patient room must accommodate an extensive array of specialized medical equipment required to care for the clinical needs of the specific patient population. Consideration also must be given to the safe and efficient use of fixed and movable medical equipment brought in to care for the patient. They also must accommodate nursing staff and the cardiac resuscitation team, if they are needed. Consequently, these rooms need to be designed to allow safe, easy access to all sides of the patient.
Once the types of equipment that could be used in the room and the location and position of the patient are known, the room layout can begin.
Room organization
A major consideration for an ICU room is getting the utilities to all the movable and portable equipment brought in and out of the room during a patient's stay. The ceiling, wall and floor space are usually at a premium in these rooms and the anticipated use of specific medical equipment will dictate the location of both the fixed and mobile medical equipment.
Types of utilities and outlets that typically need to be available in the room range from electrical and emergency power receptacles for equipment (e.g., ventilators, hemodialysis units and physiologic monitors); to low-voltage connections for various devices (e.g., television, information technology data lines for bedside physiologic monitors, electronic medical records and alarm monitoring); and medical gases (e.g., oxygen and medical air and vacuum outlets).
There are several methods of getting the utilities near the patient. Fixed floor-to-ceiling columns and movable ceiling- or wall-mounted booms have been gaining popularity over a standard prefabricated headwall or mounting the utilities directly on the walls adjacent to the patient bed. The columns provide better organization of the devices, better accessibility for staff and reduced wire and tube clutter, and fewer tripping hazards.
The columns and booms also allow for some bed movement to take advantage of window vistas, which have been attributed to patient well-being. However, window views may not always be an option due to existing external obstructions. One innovative hospital solved that dilemma by planning to install windowlike frames to display real-time camera views from several locations on the hospital roof.
If a fixed column or boom is used, space on the ceiling needs to be evaluated for proper layout, ceiling support structure and lighting requirements. Some ICU rooms may be equipped with one or two special procedural lights mounted in the ceiling above the patient for procedures that could be performed in the room in an emergency. Procedure lights sometimes are specified for ICU rooms. One model enables lights to be directed to the specific site using a wand- or wall-mounted panel.
Another consideration competing for ceiling space is the patient lift. Patient lifts can be mounted to the ceiling, installed as freestanding structures, or attached to a boom. The Facility Guidelines Institute's 2010 Guidelines for Design and Construction of Health Care Facilities identifies the need to conduct a patient handling and movement assessment and to address this during the construction process, which could have major implications for room design.
If there is a possibility of installing ceiling-mounted lifts in the future it is prudent to plan for them in the early design stages to prevent clashes with structures above the ceiling or to add structural support while the room is being planned.
Nursing staff need good visibility to the patient from the hallway. This is accomplished by using a significant amount of glass. However, sometimes privacy is needed for the patient and switchable or so-called "smart" glass is used in some units to accommodate the dual needs of privacy and observation.
With the touch of a switch, the glass changes from transparent to opaque, blocking light and providing privacy and security. This high-tech glass eliminates the need for blinds or curtains that may present an infection control risk and pose a cleaning challenge for environmental services. These glass panels are relatively expensive compared with that of standard glass, however.
Equipment needs
This is Modular Services Company's equipment solution for neonatal intensive care operations. The design team must ensure that the room is future-proofed for all of the equipment that may be fixed or wheeled into the room. It needs to consider the possible uses of the room when it is completed as well as how the room may be used in the future.
Ultimately, the type of critical care unit and patient determines which technologies are needed in the room. Most ICU rooms include ventilators; physiologic monitors mounted on a wall, boom or column; IV poles that are movable or mounted to a column or boom that can accommodate multiple IV pumps; and patient-controlled analgesia pumps. All of these may require multiple emergency-power receptacles.
Many of these devices will be integrated with the hospital electronic records through wireless connections. This integration requires that the information technology (IT) group be intimately involved with the planning of the room design and antenna placement.
Some facilities monitor ICU patients from a remote site, often called the electronic ICU or command center. For remote-monitored rooms, a pan-tilt-zoom (PTZ) camera, microphone and speakers — either ceiling- or wall-mounted — are needed to enable the remote site to communicate with the patient or nursing staff and observe patient and vital equipment displays and settings.
There is also a telepresence robot on the market that can be maneuvered into the room to gather the same type of information. This type of device requires a clear floor path through the room without wires, tubes or cables on the floor.
Intelligent patient beds are another new component in high-tech patient rooms. They not only require electrical power, but also a low-voltage data jack to connect to the hospital infrastructure for nurse-call and bed-exit alarms to monitor for fall risks. They also require connections for electronic medical records.
The flow of patient care within the room needs to be planned carefully to accommodate wireless workstations on wheels (WOWs), which typically are used for patient charting and confirmation of medication delivery. While they do not require an electrical receptacle or data jack, they take up space and need to be considered in the room layout. The typical footprint for the WOW is approximately 26 inches wide by 28 inches deep; however, newer tablet devices eventually may supersede WOWs for charting patient care.
As more and more new technology is introduced for patient care, the design team faces new challenges in providing the required utilities and adequate footprint. For example, ICU patients too ill to be moved for imaging studies need space in their rooms to accommodate mobile imaging devices like a mobile C-arm radiography or fluoroscopy unit.
The type of patient receiving care will dictate the equipment and utility requirements for the room. Here are some examples of typical ICU room equipment that have relatively large footprints and their utility requirements:
Hemodialysis equipment using continuous renal replacement therapy requires a hot and cold mixed water supply, drain and emergency power.
Ventilators require emergency electrical power, a medical air connection and a data connection for alarm management.
Hypo/hyperthermia units require electrical power.
Intra-aortic balloon pumps used in the cardiovascular ICU require emergency electrical power.
Video endoscopy carts or bronchoscopy carts require electrical power.
C-arms require electrical power.
Space also is required to ensure quick patient access by the resuscitation team with their resuscitation cart or crash cart.
Other types of ICU rooms may require very different equipment needs. For example, specialized orthopedic beds in a trauma ICU that provides for traction are usually larger and have bars that extend toward the ceiling. These require clear space above the bed to accommodate the bars. Likewise, neurologic intensive care areas may call for specialized monitoring equipment that require data jacks as well as a ceiling- or wall-mounted PTZ camera and microphone and speakers.
Point-of-care technology may have an impact on additional requirements for the design of the room as blood gas monitoring and portable ultrasound are becoming more prevalent. The key is using the medical-equipment planner to provide those glimpses into the technologies of the future of patient care and to raise the awareness of potential implications of the design on future needs.
Decisions must be made about making the investment to provide for the necessary flexibility, or at least addressing the potential impact, and designing the room to be able to add future equipment or technologies.
Beyond the ICU
Critical care areas aren't the only sections of hospitals with high-tech patient rooms. Step-down rooms and acute care rooms have their share of technologies requiring planning and installation considerations.
Step-down rooms are associated with the ICUs and have a reduced complement of equipment needs depending on the type of step-down unit. These rooms may be monitored via a telemetry transmitter that sends a patient's heart trace signals and maybe pulse oximetry to a central monitor that is being watched by a trained monitor technician. A step-down room also has a lesser requirement for both the regular and emergency electrical power systems and the number of oxygen, medical air and vacuum outlets. The design may have to accommodate fixed-ceiling patient lifts.
The acute care room has an even smaller complement of medical equipment and, consequently, less infrastructure. Some health care facilities are designing step-down and acute care rooms to be more like hotel rooms, conveying a less clinical and more comforting experience for both patients and their visiting family and friends.
Many hospitals also treat critically ill infants and children. Neonatal and pediatric ICUs have highly specialized equipment and unique room design requirements.
More of these rooms are being designed as private rooms to provide better control over the sensory environment for the neonate. Alarm management from the equipment in the room requires data jacks. Lines of site that are lost due to privacy and communication challenges need to be addressed with technology because of hard walls. Equipment to care for the neonate can be mounted on the wall or suspended from the ceiling on a boom. Utilities like regular and emergency electrical power are needed in sufficient quantity. Additionally, medical air, oxygen and vacuum are required, as are data jacks for connection to the central monitoring and the hospital information systems.
Planning for future
While considering the equipment now used in each type of room, hospital designers and facility managers must work in conjunction with clinicians to consider the potential use of the room in the future.
It is generally easier and less expensive to include additional space, electrical and data outlets, and utilities while in the design and construction phase of a project, rather than waiting until the spaces are occupied with patients and then deciding an upgrade is needed.
John J. Skreenock, HEM, is senior associate for the Applied Solutions Group at ECRI Institute, Plymouth Meeting, Pa. He can be reached at jskreenock@ecri.org.
Sidebar - Flexible rooms provide savings
A medium-sized hospital planned to renovate a couple of its acute- care nursing floors and convert all of the semiprivate rooms to private rooms, creating a new intensive care unit (ICU) step-down space.
While initial plans called for the rooms to be used for step-down patients, the longer range plan was to convert these spaces to ICU rooms when needed. For a step-down room, telemetry monitoring is sufficient. However, for future use as an ICU setting, centrally monitored, wall-mounted physiologic monitors or other high-technology equipment would be required.
With that in mind, the design had to be modified. The hospital decided to plan the rooms with increased infrastructure to handle the future conversion. Increased gas and vacuum capacity for additional outlets and additional electrical power and data jacks allowed for future upgrades.
These design changes now allow the high-technology equipment that is routinely deployed in the ICU to be used in these rooms in the future. The cost for such infrastructure at such an early stage is a fraction of the cost required in the future to convert the rooms.
However, cost is only one factor that would be considered for future conversion. If the hospital had not increased the infrastructure during the original renovation, a future conversion would have faced major complications, including the potential loss of revenue while the rooms were being renovated extensively, disruption to patient care and department operations, complex infection-control issues and a longer time to complete the conversion.
With all of these considerations, the conversion for ICU patients may never have happened.
Sidebar - Prepping for mass patient surges
When hospitals need extra space for unplanned patients in mass numbers, such as during or after a flu epidemic or a disaster with mass casualties, some facilities provide a flexible solution for allowing the census in a particular nursing department to flex up in times of need and then flex back down when the need subsides.
A portion of the acute care private rooms are designed with the ability to accommodate two patients in the same room, essentially creating a semiprivate room. This flexibility is provided by having the room designed with built-in infrastructure, such as utilities to accommodate two beds.
The design requires two headwall arrangements, each with enough gas and vacuum outlets; regular and emergency power; data jacks for plugging in equipment that communicates with the hospital's information systems; and separate lighting controls for each bed. Movable equipment required for patient care, like beds and IV pumps on poles, can be wheeled in when needed.
The second bed can be set up similar to the first but may not need all the amenities, because it only would be used for a short duration. Flexibility designed into the rooms allows for an unexpected short uptick in the hospital census.
The surge plan then will call for fixed medical equipment as well as additional mobile medical equipment to provide patient care. The mobile equipment may be relocated from another area of the facility, from storage or requisitioned from local rental firms.
This article first appeared in the August 2011 issue of HFM magazine.
Sunday, August 14, 2011
Friday, June 24, 2011
Violence In Hospitals
With complete credit to author Whitney L.J. Howell
This article first appeared in the January 2011 issue of H&HN magazine.
Security issues
Violence in Hospitals
By Whitney L.J. Howell
With attacks against staff and patients on the rise, administrators rethink security policies
Shortly after 12:30 a.m. on Sept. 3, Darrell Garner walked into Baton Rouge (La.) General Medical Center with a gun. He entered the room where his teenage stepson was a patient and argued with his estranged wife, allegedly shooting her in the arm and shooting her boyfriend in the arm and head. Local police responded quickly, but Garner apparently left while doctors and nurses treated the victims. (Ten days later, the suspect turned himself in to local police where he remains in custody.) Authorities put the facility on lockdown, and for hours, most employees got either erroneous information or none at all.
"At that time, we had no way to alert people to what had really occurred," says Edgardo Tenreiro, Baton Rouge General's executive vice president and chief operating officer. "We also hadn't yet thought about having a command center outside the hospital, so when I arrived at 1 a.m., I spent valuable time driving around our campus, trying to find the center location."
After a three-hour sweep of the facility, the SWAT team gave the all-clear and the medical center returned to normal operations.
Hospital administrators recognized that their security policies needed an upgrade. For one thing, Code White—the emergency code Baton Rouge General uses to announce violent patients—was not only inaccurate, but in this case, with a gunman involved, it also could have put at risk employees who responded to assist colleagues. The following Monday, leaders instituted Code Silver to alert staff to the presence of an active shooter.
"With the Code Silver, we're able to tell everyone to get out of harm's way—close patient doors, close doors to the unit, and barricade themselves behind desks," Tenreiro says. "In these situations, we don't want any hospital employee trying to control the individual, and we want to keep others from walking into affected areas."
Traditionally, the public perceives hospitals as places of healing—environments that are antithetical to violence. But recent data reveal a different reality. Shootings at Baton Rouge General, Danbury (Conn.) Hospital, and Johns Hopkins Hospital in Baltimore this year have prompted the health care community to re-examine security policies and procedures.
According to the Joint Commission Sentinel Event Database, 256 assaults, homicides and rapes have occurred in hospitals since 1995. The June Sentinel Event Alert showed a marked spike in activity in the last three years—since 2007, 110 violent incidents have occurred. Joint Commission officials, however, believe hospital violence is significantly underreported.
"Hospital administration makes the decision whether to report incidents, and people don't like to report violence more than they have to," says Russell Colling, a health care security consultant who serves as an adviser to the Sentinel Event Alert. "Many incidents go unreported because they don't fall into the hospital's definition of 'violence,' but others are omitted because officials don't want them to reflect negatively on the hospital's image."
The 2010 International Association for Healthcare Security and Safety crime and safety survey of 212 hospitals found that hospital crime of all kinds is rising. There were 660 aggravated assaults and 2,720 simple assaults in 2009.
Changes in the ways patients and police use hospitals place the facilities at greater risk for violent activity. A 2004 Occupational Safety & Health Administration report for health care providers on preventing workplace violence identified three substantial risks to patient and employee safety: an increased number of mental health patients using hospitals for follow-up care because so many psychiatric facilities have closed or lost beds; a rise in police use of hospitals to hold aggressive and intoxicated individuals; and 24-hour public access to hospitals.
However, neither The Joint Commission nor the OSHA guidelines include a mandate to enact any changes in security.
Not all hospital units or employees are at equal risk, however. Heavy traffic, high stress levels and the types of cases that come in make emergency departments most susceptible to violence. Intensive care units are also vulnerable, Colling says, because of elevated stress levels among patients and their loved ones.
Nurses Bear Brunt
Overall, nurses are the most frequent targets of violence because they have the most direct patient contact. A 2009 study from The Journal of Nursing Administration found that in the past three years, 50 percent of ED nurses experienced some type of physical violence, from shoving, hitting, kicking to being spit upon, and 70 percent experienced verbal abuse. In addition to patient volume and stress levels, the study points to long wait times, a lack of privacy, and anger from patients and family members as contributing factors.
Nurses are not automatically inclined to report abuse, says Diane Gurney, R.N., president of the Emergency Nurses Association. "As nurses, we feel a responsibility to assist patients who need our help, and being involved in these violent incidents has generally been accepted as part of the job," Gurney says. "But this part of the health care and nursing culture must change."
The first step to reduce hospital violence is conducting a risk assessment, says Donna Gates, a nursing professor at the University of Cincinnati. Gates works with the federal government to identify strategies for reducing the number of violent acts in health care environments. As part of an assessment, The Joint Commission recommends hospitals review crime rate records and statistics for the area around the facility and survey employees about their perceptions of risk. All disciplines must be included to identify all areas that need more security.
"Nurses and doctors tell us they want to know what to do when, they want to know what the specific guidelines are, and they want to know when to call security," Gates says. "We have to use their input to move toward a culture of safety."
This type of plan is important because it gathers top-down support throughout the hospital, says Joe Bellino, IAHSS president. By bringing together security personnel, chief nursing officers, ED managers, chief operating officers and local police, hospitals can draft and implement zero-tolerance policies that encourage all staff to report actual and perceived threats.
Data from the Emergency Nurses Association shows that hospitals with zero-tolerance policies are 50 percent less likely than hospitals without one to experience a violent incident.
Hospitals can train their employees based on the results of the risk assessment, Bellino says. Depending on the facility's experience with violent events, employees may require extensive training or they may simply need a refresher course on recognizing initial violent signs or on physical techniques to restrain patients safely. Bellino also suggests allocating funds to have an ED nurse or security officer trained to be a certified safety instructor. He or she then can customize the security information for a specific hospital.
Training employees to de-escalate a potentially violent situation is a hospital's first line of defense, Colling says. Active listening and giving patients and their visitors space can help hospitals sidestep many problems. He suggests all staff uniformly enforce such policies as the number of visitors allowed per patient at any given time to avoid prompting anger or frustration. Hospitals also should reduce the number of access points through which the public can enter.
From Police to Panic Buttons
Bellino says local law enforcement agencies should be involved in planning. "I recommend that all hospitals sit down with their local police to discuss protocols and determine the processes to respond to violence in the hospital, as well as what works best for all involved," he says. "It's optimal to invite law enforcement to the training opportunities for your employees so they know how you respond to these situations, and they learn the layout of your facility."
Sandra Schneider, M.D., president of the American College of Emergency Physicians, says doctors and nurses should become comfortable with requesting a security presence with threatening patients before violence occurs. "It's proactive, if you have a violent patient, to arrive with security and to have the officer with you the entire time," says Schneider. "But make sure the officer knows where his or her resources are and that he or she is adequately trained to quickly subdue a dangerous person."
Hospitals also can use discreet tactics to identify volatile patients and alert staff to take precautions, she says, such as color-coding charts or supplying potentially violent patients with different colored socks. ACEP supports installing panic buttons in case of emergencies.
Technology is an effective tool to prevent violence or counteract an event should it occur. Jane Lipscomb, R.N., a professor at the University of Maryland School of Nursing and an expert in workplace violence prevention, says an architect with safety experience can analyze which hospital units need additional security. The IAHSS also recommended closed-circuit television monitoring of high-risk units, metal detectors at ED entrances and electronic access controls.
The OSHA guidelines endorsed giving staff who work with volatile patients hand-held alarms that can be activated in an emergency and installing shatterproof glass in reception, triage and admitting areas.
The confusion associated with having an active shooter on hospital grounds taught Baton Rouge General two valuable lessons, COO Tenreiro says. Hospitals should establish the location for a command center outside the hospital and ensure all personnel involved in managing a crisis know the location. In addition, hospital officials need a listing of all pertinent land line and cell phone numbers, and the command center should offer Internet access to allow administrators to use such social media sites as Facebook and Twitter to communicate messages to staff inside the facility.
"Most importantly, in a situation like ours where we had an armed person in the building, you must accept that you aren't in control. The cops take over immediately," Tenreiro says. "We served as support resources only."
After a patient shot a nurse at Danbury Hospital, now Western Connecticut Healthcare, in March, OSHA cited the hospital for violence-prevention deficiencies. The hospital has implemented new strategies to better protect staff and patients, says John Lucas, director of security, including a policy posted on the hospital's Intranet home page that outlines responsibilities for the CEO on down. The hospital hired six additional security officers, bringing the total to 34, and placed some of them in the ED that serves both medical and psychiatric patients. Visitors must register at the information desk when entering the hospital and must wear visitor passes.
If a patient begins to exhibit unruly behavior, providers at the bedside may request a security consultation to determine whether the patient poses a threat. If officers identify danger, a patient will undergo a safety assessment—a detailed search of personal effects for any weapons or dangerous items. For patient behavior beyond what hospital security can control, the ED attending physician can request a call to the police by asking for a consultation with "Dr. Blueman."
"In the three months after we implemented the new safety protocols, we've seen a 75 percent drop in reported incidents," Lucas says. "Nine out of 10 conflicts are resolved at the bedside through discussion."
Whitney L.J. Howell is a freelance writer in Durham, N.C.
Facts About Violence
A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals:
97.1% of physical violence was perpetrated by patients and their relatives.
80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations.
38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures.
15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses.
13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Source: The Emergency Nurses Association's Emergency Department Violence Surveillance Study, 2010
This article first appeared in the January 2011 issue of H&HN magazine.
This article first appeared in the January 2011 issue of H&HN magazine.
Security issues
Violence in Hospitals
By Whitney L.J. Howell
With attacks against staff and patients on the rise, administrators rethink security policies
Shortly after 12:30 a.m. on Sept. 3, Darrell Garner walked into Baton Rouge (La.) General Medical Center with a gun. He entered the room where his teenage stepson was a patient and argued with his estranged wife, allegedly shooting her in the arm and shooting her boyfriend in the arm and head. Local police responded quickly, but Garner apparently left while doctors and nurses treated the victims. (Ten days later, the suspect turned himself in to local police where he remains in custody.) Authorities put the facility on lockdown, and for hours, most employees got either erroneous information or none at all.
"At that time, we had no way to alert people to what had really occurred," says Edgardo Tenreiro, Baton Rouge General's executive vice president and chief operating officer. "We also hadn't yet thought about having a command center outside the hospital, so when I arrived at 1 a.m., I spent valuable time driving around our campus, trying to find the center location."
After a three-hour sweep of the facility, the SWAT team gave the all-clear and the medical center returned to normal operations.
Hospital administrators recognized that their security policies needed an upgrade. For one thing, Code White—the emergency code Baton Rouge General uses to announce violent patients—was not only inaccurate, but in this case, with a gunman involved, it also could have put at risk employees who responded to assist colleagues. The following Monday, leaders instituted Code Silver to alert staff to the presence of an active shooter.
"With the Code Silver, we're able to tell everyone to get out of harm's way—close patient doors, close doors to the unit, and barricade themselves behind desks," Tenreiro says. "In these situations, we don't want any hospital employee trying to control the individual, and we want to keep others from walking into affected areas."
Traditionally, the public perceives hospitals as places of healing—environments that are antithetical to violence. But recent data reveal a different reality. Shootings at Baton Rouge General, Danbury (Conn.) Hospital, and Johns Hopkins Hospital in Baltimore this year have prompted the health care community to re-examine security policies and procedures.
According to the Joint Commission Sentinel Event Database, 256 assaults, homicides and rapes have occurred in hospitals since 1995. The June Sentinel Event Alert showed a marked spike in activity in the last three years—since 2007, 110 violent incidents have occurred. Joint Commission officials, however, believe hospital violence is significantly underreported.
"Hospital administration makes the decision whether to report incidents, and people don't like to report violence more than they have to," says Russell Colling, a health care security consultant who serves as an adviser to the Sentinel Event Alert. "Many incidents go unreported because they don't fall into the hospital's definition of 'violence,' but others are omitted because officials don't want them to reflect negatively on the hospital's image."
The 2010 International Association for Healthcare Security and Safety crime and safety survey of 212 hospitals found that hospital crime of all kinds is rising. There were 660 aggravated assaults and 2,720 simple assaults in 2009.
Changes in the ways patients and police use hospitals place the facilities at greater risk for violent activity. A 2004 Occupational Safety & Health Administration report for health care providers on preventing workplace violence identified three substantial risks to patient and employee safety: an increased number of mental health patients using hospitals for follow-up care because so many psychiatric facilities have closed or lost beds; a rise in police use of hospitals to hold aggressive and intoxicated individuals; and 24-hour public access to hospitals.
However, neither The Joint Commission nor the OSHA guidelines include a mandate to enact any changes in security.
Not all hospital units or employees are at equal risk, however. Heavy traffic, high stress levels and the types of cases that come in make emergency departments most susceptible to violence. Intensive care units are also vulnerable, Colling says, because of elevated stress levels among patients and their loved ones.
Nurses Bear Brunt
Overall, nurses are the most frequent targets of violence because they have the most direct patient contact. A 2009 study from The Journal of Nursing Administration found that in the past three years, 50 percent of ED nurses experienced some type of physical violence, from shoving, hitting, kicking to being spit upon, and 70 percent experienced verbal abuse. In addition to patient volume and stress levels, the study points to long wait times, a lack of privacy, and anger from patients and family members as contributing factors.
Nurses are not automatically inclined to report abuse, says Diane Gurney, R.N., president of the Emergency Nurses Association. "As nurses, we feel a responsibility to assist patients who need our help, and being involved in these violent incidents has generally been accepted as part of the job," Gurney says. "But this part of the health care and nursing culture must change."
The first step to reduce hospital violence is conducting a risk assessment, says Donna Gates, a nursing professor at the University of Cincinnati. Gates works with the federal government to identify strategies for reducing the number of violent acts in health care environments. As part of an assessment, The Joint Commission recommends hospitals review crime rate records and statistics for the area around the facility and survey employees about their perceptions of risk. All disciplines must be included to identify all areas that need more security.
"Nurses and doctors tell us they want to know what to do when, they want to know what the specific guidelines are, and they want to know when to call security," Gates says. "We have to use their input to move toward a culture of safety."
This type of plan is important because it gathers top-down support throughout the hospital, says Joe Bellino, IAHSS president. By bringing together security personnel, chief nursing officers, ED managers, chief operating officers and local police, hospitals can draft and implement zero-tolerance policies that encourage all staff to report actual and perceived threats.
Data from the Emergency Nurses Association shows that hospitals with zero-tolerance policies are 50 percent less likely than hospitals without one to experience a violent incident.
Hospitals can train their employees based on the results of the risk assessment, Bellino says. Depending on the facility's experience with violent events, employees may require extensive training or they may simply need a refresher course on recognizing initial violent signs or on physical techniques to restrain patients safely. Bellino also suggests allocating funds to have an ED nurse or security officer trained to be a certified safety instructor. He or she then can customize the security information for a specific hospital.
Training employees to de-escalate a potentially violent situation is a hospital's first line of defense, Colling says. Active listening and giving patients and their visitors space can help hospitals sidestep many problems. He suggests all staff uniformly enforce such policies as the number of visitors allowed per patient at any given time to avoid prompting anger or frustration. Hospitals also should reduce the number of access points through which the public can enter.
From Police to Panic Buttons
Bellino says local law enforcement agencies should be involved in planning. "I recommend that all hospitals sit down with their local police to discuss protocols and determine the processes to respond to violence in the hospital, as well as what works best for all involved," he says. "It's optimal to invite law enforcement to the training opportunities for your employees so they know how you respond to these situations, and they learn the layout of your facility."
Sandra Schneider, M.D., president of the American College of Emergency Physicians, says doctors and nurses should become comfortable with requesting a security presence with threatening patients before violence occurs. "It's proactive, if you have a violent patient, to arrive with security and to have the officer with you the entire time," says Schneider. "But make sure the officer knows where his or her resources are and that he or she is adequately trained to quickly subdue a dangerous person."
Hospitals also can use discreet tactics to identify volatile patients and alert staff to take precautions, she says, such as color-coding charts or supplying potentially violent patients with different colored socks. ACEP supports installing panic buttons in case of emergencies.
Technology is an effective tool to prevent violence or counteract an event should it occur. Jane Lipscomb, R.N., a professor at the University of Maryland School of Nursing and an expert in workplace violence prevention, says an architect with safety experience can analyze which hospital units need additional security. The IAHSS also recommended closed-circuit television monitoring of high-risk units, metal detectors at ED entrances and electronic access controls.
The OSHA guidelines endorsed giving staff who work with volatile patients hand-held alarms that can be activated in an emergency and installing shatterproof glass in reception, triage and admitting areas.
The confusion associated with having an active shooter on hospital grounds taught Baton Rouge General two valuable lessons, COO Tenreiro says. Hospitals should establish the location for a command center outside the hospital and ensure all personnel involved in managing a crisis know the location. In addition, hospital officials need a listing of all pertinent land line and cell phone numbers, and the command center should offer Internet access to allow administrators to use such social media sites as Facebook and Twitter to communicate messages to staff inside the facility.
"Most importantly, in a situation like ours where we had an armed person in the building, you must accept that you aren't in control. The cops take over immediately," Tenreiro says. "We served as support resources only."
After a patient shot a nurse at Danbury Hospital, now Western Connecticut Healthcare, in March, OSHA cited the hospital for violence-prevention deficiencies. The hospital has implemented new strategies to better protect staff and patients, says John Lucas, director of security, including a policy posted on the hospital's Intranet home page that outlines responsibilities for the CEO on down. The hospital hired six additional security officers, bringing the total to 34, and placed some of them in the ED that serves both medical and psychiatric patients. Visitors must register at the information desk when entering the hospital and must wear visitor passes.
If a patient begins to exhibit unruly behavior, providers at the bedside may request a security consultation to determine whether the patient poses a threat. If officers identify danger, a patient will undergo a safety assessment—a detailed search of personal effects for any weapons or dangerous items. For patient behavior beyond what hospital security can control, the ED attending physician can request a call to the police by asking for a consultation with "Dr. Blueman."
"In the three months after we implemented the new safety protocols, we've seen a 75 percent drop in reported incidents," Lucas says. "Nine out of 10 conflicts are resolved at the bedside through discussion."
Whitney L.J. Howell is a freelance writer in Durham, N.C.
Facts About Violence
A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals:
97.1% of physical violence was perpetrated by patients and their relatives.
80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations.
38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures.
15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses.
13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Source: The Emergency Nurses Association's Emergency Department Violence Surveillance Study, 2010
This article first appeared in the January 2011 issue of H&HN magazine.
Wednesday, June 22, 2011
U. of Illinois at Springfield Offers New ‘Massive Open Online Course’
U. of Illinois at Springfield Offers New ‘Massive Open Online Course’
June 21, 2011, 6:52 pm from: CHRONICLE OF HIGHER EDUCATION
By Marc Parry
What happens when you invite the whole world to join an online class?
As The Chronicle reported last year, a growing number of educators are giving that idea a try by offering free “massive open online courses,” or MOOC’s, to anyone who wants to learn. Today, that experimental idea gained some more traction in mainstream higher education. The University of Illinois at Springfield announced a new not-for-credit MOOC devoted to examining the state of online education and where e-learning is heading. Nearly 500 people from two dozen countries have registered so far, with 1,000 expected to sign up by the time the course begins next Monday.
These courses are part of a small but expanding push toward “open teaching.” Universities such as the Massachusetts Institute of Technology have offered free educational materials online for years, but the new breed of open teachers—at the University of Florida, Brigham Young University, and the University of Regina, among other places—is now giving away the learning experience, too.
The idea for the Springfield course grew out of a presentation called “The Open Future of Higher Education” delivered at a conference this spring by Ray Schroeder, director of Springfield’s Center for Online Learning, Research, and Service.
“The discussions there led me to more deeply consider the path of online learning in this era of a ‘higher education bubble,’” Mr. Schroeder said, referring to PayPal co-founder Peter Thiel’s recent claim that college is comparable to previously overvalued markets in technology and housing. Another influence was the concept of an “Open Educational Resources University,” which, as Mr. Schroeder explains it, involves students learning from freely available materials and then seeking certification of their knowledge from traditional universities.
“I found that many others also were taking stock and questioning where we are headed,” Mr. Schroeder added.
Various online-learning leaders are participating in Mr. Schroeder’s course, which runs through August 19. Not enough MOOC for you? Stay tuned. Starting in September, another group will organize what the MOOC pioneer George Siemens calls the “Mother of all MOOCs.”
In a blog post Monday, Mr. Siemens welcomed the growing interest from traditional universities. And he countered the more skeptical take offered by another open-education leader, David Wiley, who wrote recently that “MOOCs and their like are not the answer to higher-education’s problems.”
“I don’t think I’m overstating it when I say that we are at a similar point to open online learning that we experienced with the growth of the LMS (learning-management system) in the late 90s,” Mr. Siemens wrote. “While some have argued that MOOCs are limited in their appeal—mainly for professional development and highly prepared individuals—I believe MOOCs will continue to be easier to develop and deliver as the growing number of institutions develop pedagogies … and new technologies to run the events.”
This entry was posted in Distance Education. Bookmark the permalink.
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June 21, 2011, 6:52 pm from: CHRONICLE OF HIGHER EDUCATION
By Marc Parry
What happens when you invite the whole world to join an online class?
As The Chronicle reported last year, a growing number of educators are giving that idea a try by offering free “massive open online courses,” or MOOC’s, to anyone who wants to learn. Today, that experimental idea gained some more traction in mainstream higher education. The University of Illinois at Springfield announced a new not-for-credit MOOC devoted to examining the state of online education and where e-learning is heading. Nearly 500 people from two dozen countries have registered so far, with 1,000 expected to sign up by the time the course begins next Monday.
These courses are part of a small but expanding push toward “open teaching.” Universities such as the Massachusetts Institute of Technology have offered free educational materials online for years, but the new breed of open teachers—at the University of Florida, Brigham Young University, and the University of Regina, among other places—is now giving away the learning experience, too.
The idea for the Springfield course grew out of a presentation called “The Open Future of Higher Education” delivered at a conference this spring by Ray Schroeder, director of Springfield’s Center for Online Learning, Research, and Service.
“The discussions there led me to more deeply consider the path of online learning in this era of a ‘higher education bubble,’” Mr. Schroeder said, referring to PayPal co-founder Peter Thiel’s recent claim that college is comparable to previously overvalued markets in technology and housing. Another influence was the concept of an “Open Educational Resources University,” which, as Mr. Schroeder explains it, involves students learning from freely available materials and then seeking certification of their knowledge from traditional universities.
“I found that many others also were taking stock and questioning where we are headed,” Mr. Schroeder added.
Various online-learning leaders are participating in Mr. Schroeder’s course, which runs through August 19. Not enough MOOC for you? Stay tuned. Starting in September, another group will organize what the MOOC pioneer George Siemens calls the “Mother of all MOOCs.”
In a blog post Monday, Mr. Siemens welcomed the growing interest from traditional universities. And he countered the more skeptical take offered by another open-education leader, David Wiley, who wrote recently that “MOOCs and their like are not the answer to higher-education’s problems.”
“I don’t think I’m overstating it when I say that we are at a similar point to open online learning that we experienced with the growth of the LMS (learning-management system) in the late 90s,” Mr. Siemens wrote. “While some have argued that MOOCs are limited in their appeal—mainly for professional development and highly prepared individuals—I believe MOOCs will continue to be easier to develop and deliver as the growing number of institutions develop pedagogies … and new technologies to run the events.”
This entry was posted in Distance Education. Bookmark the permalink.
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