QUALITY ASSESSMENTS IN HEALTH CARE ENVIRONMENTS
Introduction
The field of health care architecture is replete with information about evidence-based design, best practice design strategies, and lessons learned from the field for various environments. Yet few of these latest studies have been replicated, and only a limited number are performed within the context of the complete hospital environment or a broad network of health care facilities. Most evaluation projects to date on health care facilities have utilized different processes, metrics, and sets of tools, hampering the transferability of findings and compromising the development of a standardized facility database that spans multiple facilities or departments.
In response, this chapter will discuss the development and pilot testing of a new structured post-occupancy evaluation (POE) approach to conduct quality assessments of medical facilities for the military health system (MHS) in their quest to build and operate world-class medical facilities. The MHS desires to build an assessment program to inform the development of evidence-based planning and design guidelines for health care projects. In particular a POE approach, framework, methodology, metrics, and data collection tools are briefly presented, offering insight on how to conduct facility-wide assessments and focused assessments within inpatient and outpatient clinical departments. Finally, lessons learned from conducting two subsequent pilot studies testing the POE methodology will be presented.
Quality assessments of health care facilities: a case study of the military health system
A series of articles that first appeared in the Washington Post reported the rundown conditions and substandard medical treatment afforded to soldiers returning from America’s wars. The recent scandal concerning the hospital system of the US Department of Veterans’ Affairs is a case in point. Public exposure of the dilapidated conditions at MHS’s Walter Reed Army Medical Center spurred interest and action toward change. Consequently, in 2008 the Health Systems Advisory Subcommittee of the National Capital Region Base Realignment and Closure Act (BRAC) was charged with reviewing the floor plans for two newly designed MHS hospitals to determine whether these facilities were designed and constructed to be world-class (WC) medical facilities. The independent review of these floor plans led to a document entitled “Achieving World-Class.” In this report, a definition of world-class facilities was presented as: “The delivery of healthcare in a state-of-the-art facility that consistently delivers superior, high quality care, translating into optimal treatment outcomes at a reasonable cost to the patient and society” (Kizer et al. 2009). With a mandate in place to create and operate world-class facilities, the MHS then initiated the development of a facility evaluation program and reached out for help from Clemson University, NXT, Noblis, and the National Institute of Building Sciences (NIBS).
This chapter highlights lessons learned from a multi-year effort aimed at developing a standardized POE process and toolkit for medical facilities utilizing complementary subjective and objective quality indicators. Compared to previous environmental evaluations, quality is assessed along a set of indicators derived from the “world-class criteria.” A case study approach was employed for the POE with two main assessment approaches: a broad-brush facility-wide assessment and focused departmental-level assessments. First, the facility-wide inquiry is a limited, broad study of the overall hospital level including all departments. Its strength is that it permits the evaluators to study departmental interrelationships to understand how the facility operates as a whole and the effectiveness of linkages across different departments. Second, at the department level, in-depth inquiries are conducted permitting the evaluators to study select departments in a comprehensive manner. Their strength is that the unit is understood at a more granular level and targeted design recommendations can be more aptly devised. Prior to starting the POE, inpatient and outpatient clinical units were identified to study. For example, the MHS selected three outpatient units including family medicine, surgery, and emergency services; and four inpatient units including general medical surgical, behavioral health, and obstetrics. The POE methodology and toolkit were developed and tested sequentially in two pilot studies leading to a refined process and set of metrics and tools. It is believed that findings from POEs may lead to ongoing improvements in the MHS facility guidance and design criteria, such as space planning criteria and room templates, as well as providing opportunities to seek best practices in facility design.
Employing a quality improvement approach to conduct health care facility assessments
An important consideration for the project was to determine an approach to guide the evaluation process and toolkit. Based on the objectives of the evaluation, the short timeline, and lessons learned from the first pilot, the team pursued a quality improvement (QI) approach rather than a scientific research approach for the second pilot. Upon review of the application, a committee determined that the project did not qualify as research according to the federal regulations and therefore did not require Institutional Review Board (IRB) approval. Instead, the POE project was deemed a QI project, a study that aims “to assess or improve an existing internal process, or local program/system or to improve performance as judged by established/accepted standards.”
Moving forward, the team proposed a four-level quality improvement process for the evaluation as shown in Figure 22.1. The first level in the process, Assessment, involves a Facility Documentation step and a Performance Evaluation step which encompass a facility-wide assessment with focused inquiries in select units. The outcome from this initial assessment is the presentation of strengths and challenges of the facility design across the evaluation criteria. It is proposed that the quality assessment should be performed repeatedly to gather data, thus creating a dynamic facility profile that relates to WC performance benchmarks. The emphasis of the work to date, and focus of this chapter, encompasses this initial Level One Assessment.
FIGURE 22.1 Quality improvement POE levels
Source: Dina Battisto and Sonya Albury-Crandall.
The second level, Diagnosis, entails in-depth explorations to further understand problem areas identified during the Assessment level. For example, in a POE of an outpatient clinic, the exam room may have received a low satisfaction score from staff and/or patients that may be attributed to its size, configuration, equipment, or lighting specifications. Therefore, additional studies are conducted to diagnose and validate the problem as well as suggest the need to review related design guidance tools such as space planning criteria and room templates. During the third level, Scenario Testing, through the fourth level, Implementation, a team works toward seeking solutions to the identified problem areas and then develops an implementation strategy to improve problem areas. Following the resolution of the problem, the team returns to Level I to conduct a follow-up assessment to determine whether the design intervention was effective. The progression through the levels is repeated as necessary. In the next section, the Level I Assessment will be described in more detail.
Development of a standardized POE framework for assessing the quality of health care facilities
Once the QI POE approach was determined, the team worked to develop POE components informed by MHS world-class principles. The nine guiding principles provided the core values and starting point for the development of the POE toolkit. These principles also informed the ongoing refinement of facility guidance criteria, such as a WC design checklist (originally an evidence-based checklist), space planning criteria, and room templates. Since the MHS wanted to understand what works and does not work in a completed, occupied facility in relation to world-class directives as well as initial design and project goals, the POE method was selected for the Level I Assessment. The POE method builds upon the longstanding work of Preiser and colleagues (e.g. Preiser et al. 1988; Preiser and Vischer 2005; Mallory-Hill et al. 2012). More information on this method can be seen in Chapter 14 in this book. Currently, POE is at the forefront in knowledge generation as it provides an assessment of design related decision-making, recommended design strategies, design concepts, and final design solutions in relation to expected outcomes. Additionally, it allows for the comparison of predicted performance captured during the programming and design phases of an architecture process, with actual performance of a building in use being captured during the POE. While Preiser and Schramm proposed a building performance evaluation (BPE) approach (1997, 2012) as an all-encompassing life-cycle approach to assessing quality, this methodology was not possible since the building was already complete when the team was approached. Nevertheless, the development of the POE methodology and toolkit evolved in a hierarchical fashion whereby the WC principles were translated into quality assessment criteria and performance indicators (Figure 22.2).
