Redesigning the SMMC NICU (Neonatal Intensive Care Unit)

1. Redesigning the SMMC NICU(Neonatal Intensive Care Unit) Using Rapid Process Design Mark Brown, Cindy Kent, Kari Tchida, Karl Ruthenbeck, Anne Porter

2. Overview of Rapid Process Design (RPD) • RPD has roots in Design for Six Sigma {GE, Taguchi} and Lean Production Preparation Process {Toyota}. • RPD rapidly creates and validates potential product and process designs that satisfy comprehensive customer and business needs. • RPD generates processes that flow better and utilize simple-right sized equipment that better meet operational needs. • RPD results in least life cycle costs due to minimum redesign. • RPD is broken into three phases: • 1) preplanning (5 wks); • 2) the planned event (1 wk); • 3) and post event (5 wks).

3. Pre Event -- A series of initial questions & answers • What physical obstacles does the current design have? All babies in one square room • Are the flows understood? Documented? There are seven flows to consider • Patient; Family; Provider; Medicine; Supplies; Equipment ; Information • Which activities (tasks) are difficult to perform? Scenarios will help to determine • 7 Wastes (TIMWOOD) -- What are the coordination mechanisms? • What are the proposed design concepts? • A long corridor with decentralized nursing stations • Have these been sketched? Yes How many alternatives? Several, very fluid plan • Have they been evaluated? Yes, via site visits and research for current NICU design trends • Has a conceptual layout been physically mocked up? No • Have operational scenarios been physically walked through? No • What revisions to the layout and operational scenarios are being considered? No

4. What were the design constraints? Urgent Driven by foundation donations & estimated budget Know historical census of patients, patient outcomes from other designs Footprint is bounded by external walls • Timing (always) • Budget (always) • Data • Physical

5. Preparing for the Event Assignments from first meeting (It takes a village): Interior Designer – Observing, Begins assembling program from discussions, Sketch artist for meeting; Suggests design options Facilities - Table and chairs for meeting; Invite Interior Designer; Find space for mockup; Provide furniture for mockup; Orchestrated mock-up construction; Brought Event Supplies (paper, markers, tape…lots of tape) Contractor – Built the full scale floor plan and four room mock up, made any changes as needed Architect - Large floor plans, Medium sized floor plans for each participant Nursing Manager - Rough draft of agendas; Medical equipment for mock room; Collect operational scenarios; Research & Site Visit Documentation Nursing – Suggest and generate operational scenarios; Video camera Unit director - Budget information; Organized Food for the event Process Excellence - Census frequency data; VOC from SMMC and NICU stakeholders; Review operational scenarios; Scribe for meeting Patient Council Manager – Invite patient representatives to the event (who had NICU experience)

6. The Rapid Process Design Event • Event that is focused on both the physical design and the processes that occur during the operation of an unit: - Discussion and questioning of how the unit operates and why. • Scenario scope is situational (e.g., from admission until the patient is discharged) • Deliverables are: 1) Physical layouts (sketches) A standard room setup (equipment, supplies, furniture, fixtures, storage); Workstations for providers and nurses, etc. 2) Documented operational models A rounding and coverage model; A visitation and emergency communication model; etc. • Propose physical design changes due to observation during mockup • Staff, management and facilities agreement on decisions made

7. Day 1 Agenda Welcome and Introductions Review of Plan Agendas Discussion of Rapid Process Design – Production, Preparation, Process Discussion of Objectives / Guiding Principles / Voice of Customer Lunch Break Review Physical Layout Scenarios – Shift Change Plan for next meeting

8. Day 1 Kickoff We are in a Rapid Improvement Workshop for three days this week (Monday, Thursday and Friday). The intent of these three days is to: • Understand the patient’s and family’s needs during a stay within a new NICU; • Determine how the new NICU should be physically arranged and • Using these proposed physical layouts, observe a number of operational scenarios that represent how the new NICU will function on a daily basis. We are engaging you as caregivers, patients and families in this process. The information collected from this session will be used to evaluate how well the performance (quality, service and safety) of the physical layout coupled with our operational approaches satisfy your expectations. This set of expectations will guide our work over the next few days. Starting with a layout of an area or areas, we will assign people to roles to carryout a set of tasks (a scenario) within the life of the NICU. There will be observers watching how well the layout helps or hinders the assignments. We will then review what worked well, what changes to the layout need to occur, and rearrange either or / both the physical layout and operational approach. We will repeat this cycle until a satisfactory solution is obtained.

9. Day 1 - VOC Voice of Customer – from new hospital stakeholders • First reviewed above with staff and patient representatives, • Then a deep dive into NICU VOC

10. Day 1 – NICU VOC Questions for Stakeholders: • What are the top 2-3 issues that are important to you when seeking / providing care? • 2) What are the best aspects of Essentia’s NICU today? • 3) What aspects of the care you receive / provide frustrate you? • 4) What do you like / dislike about other facilities that you have seen? • 5) How do you see your needs changing in the future?

11. Day 1 – NICU VOC Stakeholders: • Family members; nursing, physicians, management, facilities, infection control, security; environmental services; information management Top issues to be addressed: • Quality care • Safety • Communication of status of patient • Privacy • Preparation for discharge • Geographic/facility location of delivery • Accommodations • Bedside • Treatment • Access

12. Day 1 – Initial Plan To here From here

13. Day 1 – Initial Mockup 1 1 2 2

14. Initial Scenario -- Day 1 • Scenario #1—Shift Changeover Scenario (5 RNS are coming onto the Day shift to get assignments and report. After the assignments are made and a brief report is completed by the charge nurse, there will be bedside reporting on all patients by each RN to RN.) • Briefing: • In the mock-up lay out of NICU, there is a long distance from the conference room to the NICU rooms. • The overview from the charge nurse—is it outgoing, oncoming, face-to-face—can this be streamlined with EPIC? • Must use room numbers when making assignments. • Need map of rooms for making assignments (grease board with patient room numbers and stats on each patient). • Charge nurses to answer alarm lights while nurses are getting bedside reports. • Assignment of Roles • Multiple nurses, Charge nurse, Multiple Observers, Scenario Director (decides when enough takes are sufficient)

15. Interacting with the Mockup (Single Room) Director, Patient Families (2), Nursing, Physician Facilities, Director, Interior Designer (LHB)

16. Negotiating Room Size TAPE Architect, Facilities, Director, Interior Designer

17. End of Day 1 • Initial reactions • Looks like a very large bowling alley, long and skinny • How do we communicate? • How do we visually monitor babies? • Rooms appear cramped, due to lots of equipment and furniture • Can we add 1 ft. to depth of each room, while maintaining legal corridor width?

18. Days 2 & 3 • Scenario #2—Daily Care Rounds @ Bedside (Daily care rounds on all patients, including parents in rounds) • Scenario # 3—Daily Cares at Bedside Scenario (Where are the supplies?, Infant is getting a NT feeding of breast milk, infant has IV fluids running, infant will get Gentamicin with cares, infant urinated on all the linens and needs to have his linens changed.) • Scenario # 4—Code Scenario (Night shift with 4 RNs, Infant is at the far end of the hallway. Family is present in the room.) • Scenario #5—Admission Scenario (8 patients: 4 feeder/growers, 1 HFNC, 1 NCPAP, 2 infants with frequent spells—core staff of 4 RNs working. We are admitting a 25 week infant from a C-section) • Scenario #6—Mom after C-section (mom coming to see infant right after C-section. Infant is on ventilator and Nitric Oxide. Infant has UAC/UVC lines and is on pressors. Dad has 2nd band and is already at bedside. • Scenario #7—Discharge scenario • Scenario #8—Twins/Triplet Scenarios (Where will infants be located in the room? Where do the double headwalls go? Where does the parent bed go when 2 infants in room?)

19. Day 2 & 3 – Observations are very detailed Scenario # 3—Daily Cares at Bedside Scenario (Where are the supplies?, Infant is getting a NT feeding of breast milk, infant has IV fluids running, infant will get Gentamicin with cares, infant urinated on all the linens and needs to have his linens changed.) Observations: • The sink should be just inside the room door and supply closet filled from the outside of the room, but accessible from inside the room. • Privacy curtains in room for mom’s privacy • Nurses will be in room for long periods of time during cares. • Employee pumping room should be moved somewhere else in the hospital and the space could be used for mother’s pumping room for more privacy. • Couch is too far away from monitor for cord/wires to reach if parent is holding or feeding the infant. Still need chairs at bedside, in addition to the couch. • Medication room should be centrally located in the center of the hallway, not at either end. • Do we need a milk lab if we do not have to fortify breast milk under a hood? Yes, for long-term storage of milk. • Encourage parents to wash their hands when they enter the infant rooms and frequently during the day. • IV pump and pole needs to be on same side of bed as nurse will be to take infant out of incubator to be held by parent. • Need a chair that is mobile to be able to get closer to the bedside. • Where is the feeding pump located? • Gentamicin and pneumatic tube system were initially at one end of the hall. These must be moved to a central location, in center of hallway length. • Reminders for parents to wash hands frequently. • Vocera-type system needed for communication. • Cares will take longer with families being ever-present at the bedsides. • It is easier for mothers to be involved with infant’s cares. • Linens should be in each room. • Milk refrigerator should be elevated off floor level, if possible. More counter height. • Do the refrigerators have dividers for different families to use in one room—or no usage if multiple families in one room? • Parents need to wash hands before handling their infant, each time.

20. Day 2 – Unanswered Questions(Parking Lot) • The scenarios brought up design questions and details that would be further reviewed and developed during the design process • Communication system – sub group, OB needs to be involved • Doors and locations – RFID tracking system • Monitors – GE demo • Right and left hand rooms?? Seeing the ventilator (monitoring) (needs further discussion) • Monitor and keyboard swing arm • Wall pocket • Monitor (in room and outside rooms) • Medication scanners (bar code) (hand scanner) • Single room can be a double (non-relatives) • No breast milk storage in room • Where is the overflow? • Presence of other family without staff in room is very uncomfortable. • Monitoring station, what does it look like? • Can see both monitors? Hidden by isolette? • What is the purpose of the computer outside the room? • Can you silence alarms at the desk? How do parents know what was done? • Parent can see monitor within room. • Are monitors budget breaker?  • Proposed nursing station, glass door, mirrored headwalls, opposite

21. Day 3 – Design Observations 80% confidence recommendations • Four multiple patient, flexible rooms seems adequate • Single rooms. Given the right acuity • A lot more space than now • Med supplies and pneumatic tube centrally located • Nursing desks outside , line of sight • Parents are in room (education in the room?)(use of intranet) • Lounge – family room(multiple computers?)(connectivity of family computer / security) • Need for a family bathroom, shower • Diaper scale (dirty) in each room • All have contact & droplet isolation capabilities, do we need airborne isolation? • At least one room. Might share if same disease (single room) • A switch between negative air flows and normal air flow. • HVAC needs upgrading. Placement of vents, individual room temp control, humidity control limits (need details) • Security -- Needs involvement of security personnel, construct scenarios • Nurse wipes down space, dispose of linens, should involve environmental health • Nurse does setup, have extra isolettes, (two hours to clean isolettes in CSP), crib needs cleaning, need to set up rules for day and night time usage of the room  

22. Day 3 – Post Event Assignments • Subgroups • Communication - IT - Vocera • Room layout • Transportation/moving • Supplies – supply chain • Patient room setting • Techhnologies\vendor’s representation\requirements • Environmental Services • Communication to the rest of the department – sharing of the drawings/timelines, directions etc. • Validation with team as decisions are made • Room mock-up in existing space within the unit for continued staff input and ownership • Timelines: • Phased Construction • Infrastructure decisions to be made will help formulate timelines • Commitment from IS and Vocera – critical resource to moving forward. • In process of auditing buildings for wireless connectivity in preparation for communication system. • Medical equipment – monitors • Modular Head Walls • Detailed design • Programming will list functional space requirements & adjacencies; list equipment needed • Half day design meetings that occurred every three weeks to tackle design and get team together for longer duration to get decisions made • Get general contractor engaged

23. Day 3 – Post Event Activities Take Aways / Comments • Cut-sheets of equipment to Architect/Interior Designer • Finalize estimated project budget • Wish each project could start out like this – helps focus and important ask questions when entire team is present • NICU Staff were invited to tour mock-up and give feedback • Team was “Stoked”. Attendees were excited to begin the next steps to see a completed project. • Handling naysayers –armed with information and ability to communicate and be the ambassador for the project

24. Learning • It takes preparation (a lot) • It takes a wide diversity of people including customers • The process encourages engagement of all stakeholders • Role playing within a physical mockup is critical (and fun) • Most people can not visualize without a mockup • Helps to appreciate the true size of the new unit (bowling alley) • Need to remove the players from their daily obligations • Change management in action (lots of brainstorming) • At first the process seems overly complicated • Prevents design changes late in a design cycle • The cost of the mockup is minimal (but needs a vacant space) • Construction within an existing facility is painful, slow, $$ • Adds a staging dimension of reality • Validate new technologies !!!!

25. Visualization of Single Room

26. A Single Nursing Station per Two Rooms

27. Supply / Waste Pass Through Detail

28. Design Driven by Family & Staff Requirements

29. Overall Layout of Rooms

30. NICU in Action – A Family Story http://www.youtube.com/watch?v=2XF96qyRIx4

31. Questions Thank you for coming!!