‘Post-Lean’ and the Future of ED Design

Published on April 18, 2016
As operational processes continue to evolve in growing numbers of emergency departments around the world, adjusting facilities design can become an obvious next step, albeit an extremely challenging one. Dr. Manny Hernandez shared his insights with us on how ED facilities design can both shape and respond to how its operations and processes are formed, and how telemedicine and personalized medicine could influence your ED design very soon.

EPI: Where is emergency department (ED) design innovation coming from in 2016?

Dr. Manny Hernandez: When you think about design and innovation, there are a number of different categories that one can consider. I like to think of it from the perspective of process design, and how process and technology play into facility design. Certainly, the most advanced EDs in terms of design are in many of the more developed nations at this point. If you look at pure facility design, you tend to see the most innovation in ED design right now coming from North America and from Western Europe. Europe in particular is known as a region of the world that has very sophisticated design methodologies when it comes to physical environments, and there’s also been a strong willingness in that part of the world to really spend time thinking about and innovating in design in ways that other countries do not.

EPI: Which countries are really stepping out in terms of innovation?

Hernandez: I usually find that the greatest innovation—particularly architecturally—tends to come from the Scandinavian countries; Sweden, Norway, and Denmark tend to focus very much on design innovation as an integral part of solving a challenge. You tend to see facility design being less innovative in countries where decisions are being made solely on financial metrics.

EPI: Which design projects in Scandinavia have caught your eye?

Hernandez: The first one that comes to mind for me in Scandinavia is the Karolinska University Hospital, in Sweden. They have a number of clinicians within their organization that are strong advocates for thinking very carefully about the design of the physical environment for healthcare. Another one that comes to mind is Akershus University Hospital, in Oslo. They built a new hospital, which is now about seven or eight years old, and when it opened it was the most technologically advanced hospital in the world. They spent a lot of time thinking about the interplay between technology and the physical environment, the workforce, and patient experiences, and designed from the ground up a solution that really focused on technology as an enabler of efficiency and quality within their institution.

For example, I can think of two things that Akershus did that in my mind really helped to create better or more efficient environments. The first thing was in their clinical lab. The clinical lab in Akershus is a completely automated robotic laboratory. A human being never touches a laboratory specimen in that department unless there’s a problem with the specimen and it’s rejected by the automated line. In a typical clinical lab, you’ll often have a situation where the lab technicians will batch specimens—they’ll move a number of specimens through a process at the same time. At Akershus, every specimen that comes in is immediately processed. A robotic arm picks the specimen up out of the pneumatic tube. It logs the specimen in. If the specimen needs to be centrifuged, it places the specimen on the centrifuge. It then puts it on a robotic line that takes it through the analyzer, where are there humans manning the stations but not necessarily touching the actual specimens themselves. This results in what is probably the most efficient clinical lab in the world.

Several hospitals, including Rush University Hospital, in Chicago, are also attempting to automate aspects of their supply chain. At Akershus, in particular, they use what are called automated guided vehicles (AGVs) throughout their entire hospital. They are driverless delivery modules that can deliver supplies, logistics, food—pretty much anything—from the point of origin to the point of need without having to have a human push those carts around. This creates a lower labor cost, which is important in markets where resource availability is an issue. It can also help with what’s called a just-in-time supply chain model, so that you need to keep fewer supplies in the department, which frees up space. The interesting thing about the AGV innovation is that while that works really well, particularly in areas where you’ve got a very high cost labor market, it’s an innovation that doesn’t make sense in an area of the world where labor is abundant and labor is low cost.

EPI: What other innovations in process design are you seeing in EM that are perhaps more globally-applicable?

Hernandez: The other innovation that we’re really beginning to see now in EM, and that I’m getting particularly excited about, is operational innovation and moving into what I would call almost a “post-lean” world in the ED. In the 1990s and in the last decade, there’s been a lot of focus on lean, which I would define as applying a set of skills and tools to create a consistent, standardized a set of processes in the department that promote efficiency and outcomes. One of the things that we’ve learned in doing that is that “lean” as a tool works very well in systems where you want every input to be undergoing a similar process. We’ve begun to find that there are principles of “lean” that are very valuable in the ED, but there are things that we can do that look beyond lean to help us become even more efficient. As a result, we’re evolving into a model of streaming and/or parallel processing, in which we focus more on function and focus less on place. Practically speaking, that means we focus more on eliminating the notion that every patient has to experience their process in the ED the same way. Rather, we’re tailoring that experience and tailoring the processes the patient needs to go through to match the patient’s true needs.

EPI: In other words, personalized medicine applied in an environment where typically there has been standardized medicine.

Hernandez: Right. You can see that play out from a facility perspective by rethinking the entire patient arrival experience, and moving away from traditional triage rooms and traditional waiting rooms and space for things like patient registration, and moving towards intake zones and care initiation zones and differentiating between patients who need a bed or a trolley and those patients who can remain upright in a chair.

This also leads to another question more departments in the world are thinking about: Does every patient need to see a physician during the ED visit? For more than 30 years in the United States we have had advanced practice providers like nurse practitioners and physician assistants who care for patients in the ED. Other parts of the world are now beginning to look at that model and say: “If we have a limited number of physicians, are there other caregivers that we can rely on?” And bringing in those other caregivers can change the thinking about creating the spaces and environments needed in order to respond to them.

EPI: How is the reality of telemedicine changing the way your company designs hospital spaces?

Hernandez: The design solutions around telemedicine are partly based on whether you are a site that is seeing patients using telemedicine, or if you’re a site where the physicians and the other practitioners are actually delivering the telemedicine services. So on the patient experience side, it is about making sure that the rooms are laid out and sized to support the telemedicine technologies. Most of the technologies have become mobile, so you can wheel those pieces of equipment into the room and position them next to the patient. Some departments are beginning to explore wiring the telemedicine technologies into the room itself. Many EDs with training programs already videotape a resuscitation and use that as a teaching tool after the fact. Now it’s possible to utilize similar technologies so that you can have a physician watching the resuscitation managing the patient remotely, with the ability to zoom in and look at the patient, listen to the exam as it’s being completed, to move the camera over and look at the cardiac monitor and the blood pressure readings and the ventilator settings, and to actively assist in directing the resuscitation of that patient. This isn’t much different from how I operate as an attending working with residents now, where I stand at the foot of the bed or at the back of the room, just supervising. So that’s a very, very new innovation that is beginning to evolve.

On the side where the clinicians are actually the ones delivering the telemedicine, the focus is to ensure that there is dedicated private space within the ED for them to do their work free of distraction. It almost starts to become similar to the way we’ve designed radiologist reading rooms in the past: larger rooms with ample technologies that allow the clinicians to really zoom in on what’s happening with that specific encounter.

EPI: Most physicians, when they read about this sort of ED design, think: “Well, that sounds nice. Maybe I should move to Sweden. But I have to deal with my emergency department, which is never going to change.” So maybe we could shift gears and talk about design solutions that are achievable at a local level without an entire overhaul?

Hernandez: Absolutely. I’ve had the opportunity to work with a number of resource constrained environments. When we’re working with resource constrained environments, we must always be very careful to not walk in and assume that we know the problem and assume that we have the answer, because the challenge is often more complex than we think, and the solution isn’t the one that we would think it is. I do see very resource constrained environments that are adding very advanced technologies into their EDs, and the first question that I always ask is: Well, that’s wonderful, but then what? What do you do with that information or that patient if you have an ED that’s attached to a hospital that doesn’t have an ICU, or a hospital that doesn’t even have ventilators? Or if you’re in an environment where the closest surgeon is three, four, five, six hours, even a day away?

"The innovations that we create have to be tied to what is realistic and practical within a community and within a healthcare system. You can’t take North American solutions and drop them in India. You can’t take Chinese solutions and drop them in Europe. You can’t take Australian solutions and plunk down in Mexico. It’s just not going to work. The innovation begins with looking at the outcomes and looking at how you define value within your ED."

So the innovations that we create have to be tied to what is realistic and practical within a community and within a healthcare system. You can’t take North American solutions and drop them in India. You can’t take Chinese solutions and drop them in Europe. You can’t take Australian solutions and plunk down in Mexico. It’s just not going to work. The innovation begins with looking at the outcomes and looking at how you define value within your ED.

For example, when working in cultures where male and female patients are segregated from one another, you have to think about design solutions that don’t require duplicating costly and expensive resources unnecessarily. So when it comes to things like diagnostic imaging, if a department’s volumes don’t support having an X-ray unit for men and an X-ray unit for women, then you have to figure out how to lay out those spaces in such a way that male and female patients can access the same unit and the same resources from different directions without ever being commingled.

In environments where families and extended families are very actively engaged in the care delivery process, you have to think about designing spaces that can accommodate four, six, eight, ten people who are going to be coming and who expect to engage in and participate in the care delivery process. That certainly means bigger rooms for the patient. Sometimes it means thinking carefully about what is the family zone in a room and what is the staff zone in a room. It means having ample spaces for family members to wait comfortably while procedures are being done.

It’s also important to innovate around what the scope of care is going to be in the ED. For example, we are having a lot of discussions around the world regarding the EDs role with observation patients. If the ED is going to be providing observation or short-stay services, then how should we rethink the spaces needed for those patients, because those spaces are different on some levels than how you would design a basic ED treatment station. For example, in a general ED treatment station, you wouldn’t necessarily consider designing those rooms to have bathrooms or toilets in the treatment station. But when you get into an observation environment where a patient may be spending 12, 24 or 36 hours in that space, you typically want to design those rooms to have amenities like a toilet. You may want to design those rooms to include amenities like a chair or a sofa that lies flat, so that if a family member wants or needs to spend the night, they can do so in the room. One of the other innovations I’ve seen that is really beginning to evolve is how we think about ED design for responding to mass casualties, whether resulting from an infectious condition like we had with H1N1, or Ebola, or some of the other things that we were concerned about, like SARS in Asia almost a decade ago. We have to think differently about how we to create spaces to both accommodate these conditions and allow the ED to remain operational—where we are able to contain the potentially infectious patients from the general ED population without either population necessarily being delayed in receiving care. We have to be able to think about how to respond to the realities of a world where mass casualty incidents are becoming more frequent, and to really ensure that our departments do not become overwhelmed on the day when calamity strikes. So as we design we begin thinking about very flexible and adaptable solutions for that.

One example that I can give you is a hospital that designed the dining room in their cafeteria in a way that all of the pillars had medical gases piped into them. So if they ever had a very large mass casualty incident, the staff dining room could actually become an overflow unit for patients, allowing them to roll trolleys in and immediately have access to things like oxygen and suction and to be able to bring in portable monitors, and to be able to use that space on a very short-term basis for patient care. These types of innovations are very uncommon because most organizations either don’t think about planning for those events, or they’re unable to invest in the costs that are required to do it. They also require a constant systems monitoring and running drills in those spaces. The hospital facilities department and the biomedical engineering department have to make sure that that equipment’s being maintained, inspected, and tested, and that everyone knows where the extra equipment is stored and how to access it. I’ve seen hospitals in the past that had all these extra mass casualty carts that sat locked in some administrator’s office, and when they’re needed at 2:00 AM no one can get to them because nobody has the key. That’s a very common and preventable mistake.

Finally, the waiting rooms. When we think about waiting room space, we typically design very large and open spaces. A number of EDs that we work with now are designing separate spaces that they’re labeling the adult waiting room and the pediatric waiting room. Then, in case of a major outbreak of a communicable or infectious disease like H1N1, you can convert that pediatric waiting room very quickly from being one where you’re just putting children to one where you’re putting everyone who you suspect has the contagious condition that you’re trying to control, without mingling them with the general patient population.

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