Furniture Design Features and Healthcare Outcomes

By Eileen B Malone, RN MSN, MS, EDAC and Barbara A. Dellinger, MA, AAHID, IIDA, CID, EDAC. 

Published by The Center for Health Design, May 2011

INTRODUCTION

Quality care delivery continues to challenge healthcare leaders. The Society of Actuaries (2010) commissioned a medical claims-based study revealing that 1.5 million avoidable medical errors added $19.5 billion to the healthcare bill nationwide. In spite of intense efforts to improve patient safety and care outcomes since the Institute of Medicine published its report on medical errors over a decade ago (IOM, 1999), many chronic problems remain stubbornly unsolved, such as the failure to reduce postoperative bloodstream and urinary tract infections (AHRQ, 2010). Landrigan and colleagues (2010) found 25.1 harms per 100 admissions at 10 North Carolina hospitals over six years, 63 percent of which were thought to be preventable. The Department of Health and Human Services’ Inspector General found that 13.5 percent of hospitalized Medicare patients experienced adverse events, and another 13.5 percent experienced temporary harm, 44 percent of which were thought by physician reviewers to be preventable (Levinson, 2010). These results continue to occur despite a vast array of patient safety improvement interventions during the past decade (Watcher, 2010).

One of the many reasons for the slow progress in performance improvement may reflect the lack of complete scrutiny and consequent understanding of all the variables and their interrelatedness that shape the complex systems of healthcare delivery. James Reason (2000) hypothesized that healthcare accidents and errors occur as a result of organizational vulnerabilities. A combination of active failures (unsafe acts by those providing care) and latent conditions (termed, resident pathogens) or contributing dormant system conditions (such as chronic understaffing, inexperience, physical environment, and inadequate equipment and furniture), when combined under the right circumstances, can enable a hazard to slip through an organization’s flawed defenses. Such active failures and conditions result in patient injury and harm, as shown in Figure 1, an adaptation of Reason's (2000) Swiss cheese model of system accidents. (Download full PDF to view Figure 1)

Complete understanding of these system vulnerabilities requires human factors engineering—an approach that examines human capabilities and limitations with regard to products, processes, systems, and work environments—to maximize safety, reliable performance, and effectiveness and to reduce operational errors, operator stress, fatigue, and training and product liability (Henricksen, et al, 2009; Center for Systems Reliability, 2010). High-risk industries like aviation have long understood the role that the physical environment plays in supporting preferred human responses.

In the past quarter century, the healthcare industry has begun to embrace a growing body of work that examined the relationship between the physical environment, human responses, and consequent healthcare outcomes. Evidence-based design (EBD)—or the process of basing decisions about the built environment on credible research to achieve the best possible outcomes (Goetz, et al, 2010)—is being used by a growing field of healthcare architects, practitioners, researchers, and administrators to better understand the impacts of the healthcare environment on healthcare outcomes, including patient
safety outcomes (Malone, 2010). Maximizing infrastructure investments like the building, technology, equipment, and furniture to achieve strategic outcomes requires an internal synergy of effort between leaders who can transform organizational culture and a staff that can reengineer clinical and administrative processes, as depicted in Figure 2. (Download full PDF to view Figure 2)

Using a multidisciplinary team to execute and institutionalize the work , all of which is based on evidence-based research, pre and post occupancy measures are used to track desired outcomes, the results of which ultimately further EBD science. Additional information about the Evidence-Based Design Model can be found in The Center for Health Design’s Evidence-Based Design Study Guide 1, page 76 (Goetz, et al, 2010) at http://edac.healthdesign.org/EDAC_StudyGuide1.pdf.

Objects, such as furniture, also require careful EBD research to fully understand the role those objects play in realizing desired patient and staff outcomes. Furniture will be bought and replaced multiple times during the 30-year-plus-lifetime of most healthcare facilities. A typical new 200,000 square foot, 120-bed inpatient hospital may have over 1,600 individual pieces of furniture. Healthcare administrators often consider furniture a sunk cost, similar to walls, lighting, and heat; a facility must have furniture in order to serve patients, families, and the healthcare team. The highrisk healthcare industry demands much from these common objects, ranging from embodying an organization’s brand, providing patient comfort and support during stressful times, enabling staff to work efficiently and safely as a team, and perhaps most importantly, not contributing to patient and staff and organizational harm.

Facility managers, designers, and others charged with the responsibility of recommending furniture purchase options for c-suite approval face a dizzying assortment of choices, complicating the furniture evaluation and selection process. First-time costs frequently dictate furniture selection that overlooks facility life cycle costs and organizational performance improvement goals. The purpose of this paper is to describe the creation of an Evidence-Based Design Furniture Checklist, based on current EBD research findings and industry standards. Healthcare leaders can use the list to make informed furniture investment decisions to improve healthcare outcomes across the furniture life cycle. We conclude the paper with recommendations for future EBD furniture research, government and industry standards development, and further checklist development.