Case Study: Emergency Department Master Planning A Deeper Look An urban pediatric medical center embarked upon improving the efficiency of their clinical units within the main hospital, as well as increasing overall performance. Array led the planning efforts utilizing innovative approaches in healthcare and Lean design principles, while challenging stakeholder visions and meeting the Health System’s high standards of patient care. Array developed a facility master plan and accompanying phasing plan to implement this expansion over six phases.
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Emergency Department Master Planning Initiative CHALLENGE
PROJECT AND PROCESS OVERVIEW One of the top ranked children’s hospitals is experiencing significant growth in all service lines. To
With limited data, provide a recommendation for a flexible Emergency Department which can support future growth and changing business objectives.
SOLUTION Develop a simulation model using available data to support design recommendations and create a future road map which aligns with the Health System’s organizational, strategic and operational visions.
fulfill the medical center’s vision to be a premier pediatric health system, with leadership in advocacy, research, education and clinical care for pediatric healthcare in the nation, the hospital embarked on major facility upgrades and expansions. The hospital tasked our team to lead the development of an Emergency Department master plan that would strategically and physically improve the efficiency of the current clinical units and increase overall performance, while meeting the Hospital’s visions and high standards of patient care. The team utilized a modified version of Array’s unique process-driven project approach, leveraging Lean design principles and innovative techniques such as throughput simulation and virtual visualization to efficiently and effectively develop a facility master plan that is aligned with The Health System’s goals and expectations. The team’s approach began with a comprehensive discovery of the current state for understanding the existing physical environment and process, long term objectives and strategies which are used as parameters to provide metrics for evaluating success. Next, the team led workshops with stakeholders to explore and analyze operational models, using computer simulation to determine key factors for design and created a vision for a future process and environment. Finally, with a clear understanding of the project’s objectives, goals and future process, the design team worked with stakeholders to develop a future facility master plan and accompanying phasing plan to implement this expansion over six phases.
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Facility Assessment The team began the master plan initiative with a deep understanding of the current state. We collected and analyzed existing facility documents, reviewed previously completed studies, conducted first-hand observation and interviewed facility leadership, Emergency Department leadership as well as staff. DECONTAMINATION SHOWERS
DECONTAMINATION TANK
LEGEND FIRE RATED VERT. TRAN. PENETRATIONS INFRASTRUCTURE SPACES AREAS NOT REQUIRED TO WITHIN LEVEL 1 EMERGENCY DEPARTMENT RAISED SLAB (ABOVE FIRST FLOOR LEVEL) AREAS AVAILABLE FOR EXPANSION TO BE RELOCATED WITHIN EXISTING AREA
LEVEL LEVEL 1 1 EXISTING CONDITIONASSESSMENT ASSESSMENT EXISTING CONDITION
EXISTING EMERGENCY DEPARTMENT BOUNDARY
P0 LEVEL LEVEL PARKING EXISTING CONDITION ASSESSMENT EXISTING CONDITION ASSESSMENT
EXISTING CONDITION ASSESSMENT The Emergency Department is located on Level 1 of the East Building. In order to expand its footprint and provide a cohesive future master plan, our team worked alongside the facility’s Asset Development Manager to identify and assess potential areas for expansion both within and adjacent to the Emergency Department’s current boundary. The following areas were identified as potential areas for growth:
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Level 1: 1,300 SF enclosed northeast area of the Medical Center
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Parking Level 0: 18,000 SF parking, ramp and service areas below the Emergency Department’s administrative suite
Our team collaborated closely to confirm feasibility and identify impact of expansion. These impacts included: required modification of structure, life safety system and additional infrastructure systems. Modifications within the footprint of the Emergency Department were also analyzed.
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Current State Process Analysis DIRECT OBSERVATIONS To better understand current clinical processes and work flows, Array conducted direct observations. These sessions occurred during the weekdays with multiple team members present. Each team member traversed through a typical patient’s experience by randomly selecting a patient at arrival and recording all interactions and steps during their visit. After initial observation, the team conducted interviews with selective facility and clinical leaders to ensure alignment with the Health System’s long-term strategic goals. Additionally, the leadership team participated in a discovery workshop to identify key successes and obstacles of the current work process.
STAFF INTERVIEWS AND DISCOVERY WORKSHOP After initial observation, Array conducted interviews with select facility and clinical leaders to ensure alignment with the Health System’s long-term strategic goals. Additionally, the master planning team led a discovery workshop to identify key successes and obstacles of the current work process, as summarized below: Current Successes
Obstacles to Flow
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Patient satisfaction
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Patient acuities are collocated during waiting
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Team collaboration
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A level 3 or 4 patient may stay longer due to non-emergent symptoms
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High level of care
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Three (or more) nurses may care for a patient during their visit
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High level of patient safety
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Patients waiting and examined in corridors
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Fours treated in main ED because the Remote Terminal Unit is full
DATA PROVIDED BY LEAN STUDIES We were able to utilize data collected from previous Lean Studies as a starting point for analysis and simulation. The Lean team collected detailed and objective data for each of the steps in the work flow, identified some of the trouble spots and desired features for state future design.
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Designing the Future State RESEARCH AND EXPLORATION OF OPERATIONAL MODELS Our team led an exploration workshop with the master planning team to evaluate and consider alternate delivery models from other emergency departments around the nation of similar scale. These care delivery models included a wide range of practices, including both standard and unique operational approaches in the industry. In this workshop, representatives from ED, Security, Registration and Materials Management amongst others, engaged in an active dialogue to understand advantages and disadvantages of each delivery model, the benefits if implemented at the facility’s unique environment, as well as feasibility and obstacles to implementation. This important research and exploration step prepared the master planning team to design a future state that is based on knowledge of the industry and facility’s unique operations. FUTURE STATE PROCESS MAPPING
Building on information obtained in the Discovery phase, the current state operations and physical environment were reviewed and analyzed as part of a workshop facilitated by our team. During this workshop, the master planning team envisioned and designed a future state process and environment that addressed the challenges that were identified. KEY FEATURES OF FUTURE STATE PROCESS
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Creating a linear, welcoming patient experience. Patients are not asked to wait in the same waiting room repeatedly between steps.
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Streamlining registration and check-in which enables higher level of patient safety as patients are triaged by a provider within minutes of arrival.
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Creating separate and discrete waiting for patients of varying emergent levels.
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Designing universal, all-private rooms with flexibility for clinical operations so all rooms can be used for any level of acuity.
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Future Master Plan Our team explored various planning models and architectural solutions. These architectural options explored varying degrees of expansion and renovation, different operational models such as centralized or decentralized support areas as well as private and semi-private rooms. The proposed master plan includes the following design components: Arrival and Triage (6,200 SF): Expanded welcoming area to include triage with five private rooms and three sub-waiting spaces, to match newly established future state security/triage process. Treatment Area (26,400 SF): Fifty-six private treatment rooms supported by three team and support areas and opportunities to separate smaller pods of rooms. This approach maximizes flexible use of patient rooms, increases safety by providing visibility to all treatment rooms as well as promoting a collaborative clinical team approach to patient care. Administrative Area (7,500 SF): Includes all staff, administrative and support areas such as staff lounge, office space and collaboration spaces.
1.
2.
3.
4.
Patient arrival area features an integrated 15 security and registration area. ED patients bypass Medical Center’s security process and are immediately under nurse oversight, reducing delay and increasing patient safety.
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RTU is flexible in size and accessible to acute areas within ED.
19 19.1
20
20.2
ELEC
20.9
21
22
TREATMENT 130 SF
ELEVATORS (E)
12
23
TREATMENT (E) 156 SF
TREATMENT (E) 156 SF
11
TREATMENT (E) 158 SF
TRANSPORT (E) 182 SF
TREATMENT (E) 158 SF
TREATMENT 141 SF
TREATMENT 140 SF
OPEN TEAM AREAS POC LAB
TREATMENT
FAMILY GRIEF
6
STOR
OPEN TEAM AREAS
TEAM IMAGING SUBWAIT
TRAMA (E) 484 SF
Support spaces and supplies are centrally located.
MEDS
SOIL
TREATMENT 130 SF
TREATMENT 130 SF
XRAY (E) 322 SF
TREATMENT 137 SF
CLEAN
NOURISH
TRAUMA (E) 457 SF
TREATMENT 134 SF
LAB
STAFF AMENITY
TREATMENT 130 SF
TREATMENT 130 SF
TREATMENT 137 SF
8
TOILET
TREATMENT 152 SF
MECH
TREATMENT 154 SF
MEDS
SOIL
9
TREATMENT 167 SF
UP
TREATMENT 128 SF
5
TOILET
TREATMENT 137 SF
OPEN TEAM NOURISH AREAS
TREATMENT 143 SF
C TREATMENT 139 SF
TREATMENT 160 SF
TOILET
4
SOIL
D
TREATMENT 124 SF
STAFF AMENITY
OPEN TEAM AREAS
SCHEDULING OFFICE EDUCATION STORAGE
TREATMENT 121 SF OPEN TEAM AREAS
TREATMENT 122 SF
CLEAN
E
TREATMENT 135 SF
TEAM 143 SF
TREATMENT 133 SF
POC LAB
TREATMENT (E) 137 SF
MAIN ED WAIT 276 SF
TREATMENT 153 SF
NOURISH
TREATMENT (E) 145 SF
B
TOILET TREATMENT 162 SF
MEDS
TREATMENT (E) 141 SF
TREATMENT 128 SF STAIR
TREATMENT 128 SF
CLEAN
TREATMENT 179 SF
STAIR
TREATMENT 130 SF
TOILET (E)
? TOILET
TREATMENT 164 SF
13 POSITIONS
16 POSITIONS
TOILET
TREATMENT 130 SF
10
TREATMENT FEMALE DECONTAM 577 SF
TREATMENT (E) 161 SF
TREATMENT 127 SF
TREATMENT
MEN DECONTAM 571 SF
TOILET (E)
5.
18
A
With simulation studies, design team recommends five private triage rooms to be fully staffed at busiest times to reduce wait time for patients first encounter with providers. Separate waiting rooms for Rapid Treatment Unit (RTU) and main Emergency Department patients after triage creates a linear flow for visitors.
17
21 POSITIONS
7
TREATMENT 133 SF
TREATMENT 123 SF
TREATMENT 132 SF
TREATMENT 132 SF
TREATMENT 130 SF
TREATMENT 131 SF
TREATMENT 132 SF
REGISTRATION
TREATMENT 124 SF TREATMENT 121 SF
F
6 POSITIONS
6.
Open Team Areas promote collaboration of the entire clinical staff while maintaining visibility to treatment rooms.
CT (E) 415 SF
ELEVATORS
CT CTRL (E)
TREATMENT (E) 140 SF
TREATMENT (E) 139 SF
TREATMENT (E) 140 SF
TREATMENT (E) 140 SF
RTU WAIT 915 SF MAIN ED WAIT 1,114 SF
TRIAGE CORRIDOR
DATA
7.
8.
9.
New master plan supports opportunities to cluster patients with similar treatment needs, increasing efficiency of staff work flow.
TRIAGE 105 SF
10. Behavioral Health patients can be safely separated from the main ED within a smaller sub-unit as needed.
TRIAGE 105 SF
TOILET MALE (E)
TRIAGE 105 SF
VEND
ELEVATORS (E)
REGISTRATION OFFICE
G
TRIAGE 99 SF
1
SECURITY 143 SF
TOILET FEMALE (E)
Within team work area, a mixture of open and semi-private workstations are provided to address varying needs of team members. Exit stair and electrical rooms have been modified to allow more direct circulation within the Emergency Department.
TRIAGE 106 SF
P.O.C. LAB
3 2 WAIT 1,639 SF
H
TOILET 86 SF HOSPITAL SECURITY
ED ARRIVAL
J
11. 1.
Fifty-six all-private treatment rooms are universally designed to accommodate varying acuity levels.
2. 12.
Decontamination showers have been moved closer to the ambulance entrance to create a more coherent layout for the Emergency Department while maintaining identical work flow.
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\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ VISUALIZATION Employing state-of-the-art visualization technology, our team created a virtual walk-through of the proposed future Emergency Department. The below virtual tour provided the Medical Center’s master planning team a clear picture of the future state as envisioned and confirmed key spatial architectural features.
1
2
Arrival waiting space features access to natural light
Triage includes an efficient staff work area as well as
and integrated security and registration area.
point-of-care lab.
3
4
Separate RTU waiting area is established to provide a
Universal treatment rooms and team areas provide
more welcoming environment while effectively addresses
operational flexibility in case of changes in future
varying patient needs and is accessible to registration
care delivery model.
to further allow most efficient throughput.
6
5
Support and supplies are centrally-located within
Open team areas provide excellent visibility to treat-
each treatment pod and immediately accessible to
ment rooms while continue to promote and support the
both team areas in each pod.
successful collaboration within the clinical team.
7
8
New master plan supports opportunities to cluster
Semi-private work spaces will be included within open
patients with similar treatment needs, increasing
team areas to support varying needs of staff work
efficiency of staff work flow.
within treatment space.
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Who We Are
Project construction is planned to be completed in mul-
ARRAY-ARCHITECTS.COM
tiple phases in order to maintaining full operations of the Emergency Department. Phase I Relocate administrative and staff areas directly beneath current offices. This will include physicians, nurses, administrative staff, staff lounge, Security and Trauma Services. Phases II and III Build treatment and support areas where offices and decontamination showers are located. Relocate
We Are Healthcare Architects We are a team of architects and designers with unique backgrounds, but we all have one thing in common - we share a strong desire to use our expertise and knowledge to design solutions that will help people in moments that matter most.
Phases V and VI
This focus makes us leaders in our field. There’s a degree of compassion, empathy, and sensitivity that goes into every project that we touch. It’s designing a nurse station with sight lines to every patient. It’s building a Behavioral Health facility without corners, so that patients are safe. It’s translating the operational needs through the technical details to fine tune the lighting system in a neonatal unit so caregivers can match the lighting to each baby’s stage of development. It is a deeper understanding,
Gradually renovate existing treatment and support spaces to
honed through relationships spanning decades.
decontamination showers to northwest side of the Department, accessible from existing ambulance entrance. Phase IV Renovate, expand and improve reception, triage and waiting areas in two phases to minimize disruptions.
create newly envisioned treatment areas with safer lines of sight, team collaboration space and centrally-located support spaces. This future road map aligns with the Health System and
Together, we discover optimal solutions with our clients. It is our four decades of specialization that allows for effective communication, collaboration and precision in the complex, changing world of healthcare.
Emergency Department’s organizational strategic and operational visions. Additionally, the facility master plan will support the future state operational work flow and improvements as established in this project, and provide a flexible approach for future expansion.
Array’s Knowledge Communities We believe strongly in sharing our expertise and knowledge with others. We invite you to explore each of our thought leaders and share your thoughts with the healthcare design community. Click here to visit our Thoughts page.
Click here
to view our thought leadership on emergency departments
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