Simulation expert Nora Colman researches the influence of architecture and design on patient safety. In this interview, she explains the benefits of early simulation for planning.
Nora Colman, how do you persuade hospital managers and architects that simulation pays off?
Nora Colman: By highlighting the potential safety gains and cost savings. We know that the built environment has an effect on patient safety. Poorly designed spaces push up staffing costs because they operate inefficiently and they can cause expensive safety issues.
Who usually has the idea of using simulation during planning processes?
During the planning process, architects will hit on questions that hospital management have difficulty making a decision on. That gives the architects a chance to say: «Let’s test this in a simulation. That way, we will gain a fuller set of information to help with the decision.» At the same time, management has an opportunity to say: «This space will look completely different from what we’re used to. We want to ask our clinical teams for feedback so we can make the right decision.»
How does simulation benefit architects during the planning process?
«Work as imagined» is rarely the same as «work as done». Planners can design a space and imagine what it will be like in use, but the reality is often different. Clinical staff may interact with it completely differently. Simulation makes these differences visible.
What do clinicians gain from simulation?
They often find it hard to translate a two-dimensional drawing into the context of their work. If a space does not meet their needs, they will develop alternative solutions to simplify their work. However, these alternatives may be unsafe or inefficient, which is why it is important to involve clinicians at an early stage of planning.
Can you give an example?
When we were building our hospital in Atlanta, we planned how the space was to be divided up and made sure all items of equipment had their place. It all looked great on paper. But when clinicians used the space in simulation, they were no longer able to reach the head of the bed once the patient was hooked up to equipment. Simulation forces architects and hospital managers alike to think beyond the typical planning process. It helps everyone see the architecture from the perspective of the people who will actually be using the space.
So architecture not only has an effect on quality of care, it also affects employees’ well-being?
Designing rooms without clinical input leads to overstretched employees. Clinical staff do not want to work in spaces that are not designed for their needs. Hospitals that do not involve their employees in planning processes are sending out a message that they do not value their opinions, which further undermines morale and increases employee turnover. And that turnover costs a lot of money.
In your experience, are architects willing to embrace the simulation process?
We are seeing a shift in culture in the United States. Architects are increasingly involving end users in their processes, but hospital management teams also have to be open to the idea. Simulations often lead to design changes and both parties have to be willing to accept these. The aim of simulation is not to criticise the architecture, but to refine and improve it so as to achieve the best possible result.
Can’t hospital architecture be standardised?
There are very subtle differences in the way healthcare is delivered, and delivery can vary tremendously from hospital to hospital, country to country or even team to team. There is no «one size fits all» solution to hospital design because each system organises care in a different way. Architects have to find a balance between standardisation and individualisation. They can only do that if they work with clinicians to understand how care is delivered in their specific environment.
How do you make sure that architects and hospital managers communicate effectively with each other during the simulation process?
All participants need to share an understanding of the goals and limitations of simulation. There may be design features that cannot be changed, and that needs to be clear from the outset. We also use tools such as failure mode and effects analysis (FMEA) to prioritise problems by safety and efficiency criteria. It is important that the architect and hospital owner agree on how decisions are to be made once simulation has taken place. Decisions have to be taken right to the top to ensure that the findings from the simulation are implemented.
Simulations are expensive and cost is often a stumbling block.
Cost is a particular issue for hospitals. Simulation needs time and people, which is off-putting at first. But it doesn’t have to be expensive. We can scale simulations for anything from a single space to a complete department. The aim is to make the long-term cost savings clear to the hospitals. The earlier you detect planning mistakes, the cheaper it is to fix them.
Do you have an example?
We use an approach called the cost-influence curve, which shows how changes involve little cost during the early planning phase, but get a lot more expensive once construction has begun. In one case, an emergency department had to be completely rebuilt at a cost of millions. Using simulations, we can identify such problems at an early stage and make long-term savings in both construction and operating costs.
What role can the SCDH play in this process?
Using simulations to review hospital design is a relatively new application. Very few people know how to conduct them correctly. Even using a hospital simulation for training isn’t the same as investigating a physical environment. And architects who specialise in hospitals don’t have the knowledge either. The SCDH provides the space and expertise needed to perform simulations.
Can this expertise extend beyond planning individual projects?
The SCDH is neutral and not affiliated to any particular firm of architects, hospital or supplier. That makes it the ideal place for cooperation and innovation. It provides a space in which to bring architects, clinicians and hospital management together. It is a unique platform that could set a new standard in architecture for healthcare facilities all over the world.
What does that mean for architects?
Architects could use the SCDH to develop skills that they could use in various countries. You could integrate healthcare professionals from ten different hospitals into a universal architectural design. A design of this type with these specific features would work for many projects. And you could further improve this basic design and adapt it to individual needs.
Nora Colman is an Assistant Professor of Paediatrics and a Critical Care Medicine Physician at Children’s Healthcare of Atlanta (USA). The simulation expert researches the effects of architecture and design on patient safety. Colman has organised many large simulation projects in hospital planning and led a two-day workshop entitled «Hospital design and care delivery» at the SCDH.