It was some years ago when I was at an annual meeting of the Institute for Healthcare Improvement that I heard Don Berwick say something like "every system is perfectly designed to get exactly the results it is getting." I can't recall the date or the exact words, and he may even have been quoting someone else, but it stuck with me from that moment. A Google search suggests the concept may go back to Deming's thinking about systems. Design of the system leads inevitably to the outcomes we are receiving.
In 1978, Donabedian1 introduced the famous and exquisitely simple structure-process-outcome model for health care systems, and in 2006, Carayon and her colleagues2 proposed revising his model, substituting the environment, tasks, technology and tools, organization, and person as 5 elements to replace structure. They explained that the "work system in which care is provided affects both the work and clinical processes, which in turn influence the patient, employee, and organizational outcomes of care."2(pi51) Design of the entire work system is therefore crucial to the obtained results.
This issue tackles some vital topics related to intensive care unit (ICU) design and its impact on patient safety. Patient safety and quality have been high profile topics for health care, and critical care in particular. We know that critical care is not acceptably safe as a result of numerous studies that have followed the Institute of Medicine reports, To Err Is Human: Building a Safer Health System3 and the subsequent Keeping Patients Safe: Transforming the Work Environment of Nurses.4 Much work continues as efforts are made to consider how design impacts safety in the ICU.
One of the earliest initiatives to improve staff efficiency and patient safety was to decentralize the traditional nursing station and bring documentation and communication functions closer to the patient's room. Charting alcoves were created as one solution, but these may limit views of other patient rooms and serve as barrier to communication among nurses. Hamilton, Swoboda, Lee, and Anderson consider the pros and cons of various architectural solutions in their article, "Decentralization: The Corridor Is the Problem, Not the Alcove." They propose both design modifications and human engineering solutions for improving patient safety and decreasing nurse isolation.
Nurses have a unique perspective and strong opinions about unit design and patient safety. A study posted on the Web site of the American Association of Critical-Care Nurses garnered valid responses from nearly 600 nurses and identified factors that respondents perceived as vital elements to consider when planning an intensive care environment. In their article, "Evaluating Nurses' Perception of Patient Safety Design Features in ICUs," Islam and Rashid report study findings that should prove helpful to hospital planners and architects.
"Deriving Information Requirements for a Smart Nursing System for Intensive Care Units" by Khanade, Sasangohar, Sutherland, and Alexander reports their study on "smart tools" and other strategies that appear to be useful for measuring stress and fatigue among nurses. The authors emphasize that the eventual design for a wearable stress-monitoring system must incorporate informational needs of both nurses and their managers and serve as a tool for reducing fatigue that leads to inefficiency and clinical errors.
"Environmental Infection Prevention: Priorities of Patient Safety Collaboration" by Grota and Grant addresses the multifactorial issues associated with health care-associated infections. The authors emphasize that ICU nurses must facilitate team efforts of environmental services, infection preventionists, and others to ensure that risks are minimized for cross-contamination within the patient's environment. Unit design factors, medical equipment maintenance, and personnel adherence to infection control guidelines are among the essential elements for reducing risks related to drug-resistant environmental pathogens.
Hassan's contribution, "Tele-ICU and Patient Safety Considerations," emphasizes that technology alone is not likely to improve clinical outcomes. However, it permits data processing that contributes to the development of predictive algorithms. Collaborative efforts between remote and bedside teams are essential for ensuring care processes that result in clinical efficiencies and patient safety improvements.
Informatics systems are vital components in today's ICUs, and designing a unit involves considerations of current and evolving technology. "Informatics for the Modern Intensive Care Unit" by Anderson, Jackson, and Halpern outlines challenges associated with the "smart ICU." The authors emphasize the importance of interdisciplinary collaboration during planning and design to ensure that host needs are met and that safety and security concerns with vast network connectivity are thoughtfully addressed.
"Safety and Security Concerns of Nurses Working in the Intensive Care Unit: A Qualitative Study" by Keys and Stichler highlights vital elements as perceived by staff members. In addition to census controls and adequate staffing, nurses noted other key factors impacting safety and security. These included unobstructed visibility of patients and coworkers; access to multiple exits; and the capabilities to "lock down" the unit in the event of a threat scenario. Nearly all respondents mentioned adequate staffing as the most important attribute of a safe, secure care environment for patients and families.
"Direct Observation of Medication Errors in Critical Care Setting: A Systematic Review" focuses on the human factors associated with the administration of pharmaceuticals. Investigators Foster, Gary, and Sooryanarayana discuss the several human factors identified as root causes of medication errors. Adherence to strict guidelines associated with every step of the process from prescription writing to the eventual delivery of the drug to the patient is vital for preventing medical errors, some of which could be life-threatening.
I hope clinicians and their design collaborators will find something useful in this issue and will consider design and systems thinking as they plan new ICUs. Patients, nurses, and the interdisciplinary staff of critical care units surely deserve to experience improved safety and quality outcomes.
-D. Kirk Hamilton, PhD, FAIA, FACHA, EDAC
Issue Editor
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