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Dialogue: Standards Bearer

Ramponi: "Many factors within the physical environment can impact on the health and wellbeing of patients."




 
Primum non nocere. Never before has patient safety been so high on the agenda, fulfilling one of the principal precepts taught to all medical students, that the first consideration of a medical intervention must be ‘First, not to harm’.

The Joint Commission International (JC) has been working with healthcare organisations and Ministries of Health in more than 80 countries since 1994. It focuses on improving the safety of patient care through accreditation, as well as through advisory and educational services aimed at helping providers implement practical and sustainable solutions. More than than 200 organisations in 33 countries have been acreddited by JCI, including clincical laboratories, hospitals, medical transport organisations, care continuum services, ambulatory care facilities and primary care services.

Through JCI accreditation and certification, healthcare providers have access to a variety of resources and services that connect them with the international community: an international quantity measurement system for benchmarking; risk reduction strategies and best practices; tactics to reduce adverse events; and annual executive briefing programmes.

Carlo Ramponi has been working with JCI since 2000 as a project manager in Italy and then as an international consultant, before becoming managing director of its European office. His vision is to provide European hospitals with recognition through international accreditation that can be used as a tool to benchmark standards for safety and quality.

He wants to develop an EU-wide network of accredited healthcare facilities, support private and public organisations, including Ministries of Health, regional, cantonal and local authorities and create an environment in Europe where people feel confident that they can rely on a network of safe hospitals.

Here, Ramponi talks to Design & Health president, Prof Per Gunnar Svensson about the value of research, evidence-based design and the healing arts in improving human health and wellbeing.

Per Gunnar Svensson: How important is design and architecture to health service provision?

Carlo Ramponi: The Robert Wood Johnson Foundation funded the first ever meta-analysis of over 600 articles that discussed the effect of facility design on the outcome of medical care. The findings from this study demonstrate that many factors of the physical design can impact on the wellbeing of both the patients and the caregivers.

One of the most important findings concerned the use of natural light. It was noted that having access to daylight reduced the length of stay for patients and improved the morale of caregivers.

A second finding demonstrated the importance of design in reducing infections: private rooms, effective air handling and sink placements can all help to reduce the spread of infections in healthcare faciliities.

Minimising sound decibels is also important for patients to ensure a calm and restful environment for recovery. By lowering noise levels, caregiver fatigue can also be reduced.

Those are just a few of the findings to date, as new knowledge is created from research projects that are using new techniques to study and publish information in this new and fast developing field.

P-GS: How important is flexibility in hospital design to accommodate future changes in technology, work patterns and practices?

CR:
The Robert Wood Johnson Foundation funded the first ever meta-analysis of over 600 articles that discussed the effect of facility design on the outcome of medical care. The findings from this study demonstrate that many factors of the physical design can impact on the wellbeing of both the patients and the caregivers.

One of the most important findings concerned the use of natural light. It was noted that having access to daylight reduced the length of stay for patients and improved the morale of caregivers.

A second finding demonstrated the importance of design in reducing infections: private rooms, effective air handling and sink placements can all help to reduce the spread of infections in healthcare facilities.

Minimising sound decibels is also important for patients to ensure a calm and restful environment for recovery. By lowering noise levels, caregiver fatigue can also be reduced. Those are just a few of the findings to date, as new knowledge is created from research projects that are using new techniques to study and publish information in this new and fast developing field.

P-GS: How important is flexibility in hospital design to accommodate future changes in technology, work patterns and practices?

CR:
Rapid technological advancements and the rising cost of healthcare in every country make flexibility in physical design a mandatory requirement. Healthcare organisations must have the ability to respond to new patterns of care provision and new technologies without having to build expensive new facilities.

Ten years ago, few hospitals were considering a future with a robot at the surgical table while the surgeon worked in another room or from a remote site. Yet, this is now becoming commonplace, particularly as a means of remotely carrying out surgical procedures in under-served areas of the world.

Surgical spaces need to be able to accommodate this intrusion of equipment, which calls for more diverse space requirements to be met. It is hard to know what may be on the horizon, but we can be sure that current and traditional methods of providing care will change or even become obsolete. History has taught us that technology moves on and different space configurations will be needed.

Prof Svensson: "How important is research and the concepts and methodologies of evidence-based design?"

P-GS: In international hospital development, how important is research and the concepts and methodologies of evidence-based design?

CR:
To demonstrate our commitment in this area, we launched the Safe Design programme last year. This programme incorporates the environment of care standards for buildings, life safety codes as well as the new evidence-based criteria for health design. We have already begun working in the international community to bring together these concepts for facility design.

Professor George Mann at Texas A&M University has helped to build hospitals around the world for many decades. In a recently published article entitled, ‘Toward an international architecture for health practice’, Mann reminds us that healthcare facility solutions must be appropriate for the country they are serving1. New projects, he says, should be approached only after asking these crucial questions:
•  Is the project needed and is it feasible?
•  How are resources, staff and facilities going to be successfully aligned to provide the care needed?
•  What are the available power and utilities structures?
•  What are the health challenges for the country, for example, diseases, age, infrastructure, culture etc?

These represent just a few of the questions to ask in the planning of healthcare facilities, particularly in economically disadvantaged countries.

At the Union of International Architects Public Health Group annual conference held in Florence in June last year, the need to separate patients by ethnicity, culture and social status were identified by speakers in some countries as crucial to the health and wellbeing of those being cared for in healthcare settings.

Other topics included how to embed a culture of innovation and an approach to flexible design that accommodates changes and respects ‘humanity’ through a design philosophy that reflects patient needs. The ‘humanistic’ imperative has led some thought leaders to describe evidence-based facility design as a new social movement.

P-GS: At the forthcoming 6th Design & Health World Congress and Exhibition in Singapore in 2009, the majority of presentations are focused on middle- and high-income countries. How do we turn our attention to the developing world?

CR:
Developing countries are often neglected on the world stage, but it is crucial that as we research the new methods being used in developing facilities that we explore what can work in countries where there is limited access to basic infrastructure. JCI is committed to working with developing countries to maximise their outputs from limited resources. Its recently developed International Essentials of Health Care Quality and Patient Safety initiative takes account of the basic needs for patient safety, and considers the needs of developing countries.

P-GS: What is the value of the connection between design and culture, in particular the use of art, music and colour to reflect local social context?

CR:
Research studies have demonstrated that music when provided to children in emergency rooms reduces stress levels, as well as the pain experienced by the child. Other studies performed on adults demonstrate that the music of the patient’s choosing can assist in reducing stress, decrease blood pressure and improve other stress-related ailments.
For example, adult patients in a procedure room reported better pain control when exposed to a nature scene with nature sound in the ceiling2. In a 2002 study at the Hong Kong Polytechnic University, researchers found that, with visual stimuli (a soundless nature video) there was a significant increase in pain threshold and pain tolerance3.
According to Ulrich and Gilpin4, research suggests that art with views or representations of nature will promote restoration if “it contains the following features: calm or slowly moving water, verdant foliage, flowers, foreground spatial openness, park-like or Savannah-like properties (scattered trees, grassy undershot), and birds or other unthreatening wildlife.” Ulrich and Gilpin4 also suggest that, in addition to nature art, humans are genetically predisposed to notice, and be positively affected by smiling or
sympathetic human faces.
In a landmark study published in 1984, Ulrich5 found that postoperative gall bladder surgery patients whose rooms had windows with views of a park enjoyed better outcomes than patients whose rooms had windows with views of a brick wall. Patients also complained less to staff, needed analgesic pain medication of lesser strength and were discharged earlier.

PG-S: What is the focus of JCI’s Safe Design programme?
CR: In the Safe Design initiative, assessment and intervention are integrated into the customers planning, design and construction process. The JCI team will maintain a relationship with the customer, ideally as one of the planning members.

As the project progresses and new issues arise, the JCI team members monitor design impacts on safety and quality and advocate for the safety perspective in decision-making. JCI’s goal is to design safety into a facility plan from the start of the project in the same way as other functional elements are included, such as plumbing and support beams.

PG-S: Will JCI include architectural and design criteria for healthcare facilities in its future standards development?
CR: JCI has already incorporated some of the more basic evidence-based practices into its standards, such as sinks for hand washing and adequate ventilation to reduce the potential for the spread of healthcare-associated infection (HAIs) from airborne infections. As the healthcare field develops more evidence-based practice findings, JCI will closely monitor which may be essential to the delivery of safe and high quality care, and should therefore be developed as a minimum standard or promoted as best practice.

Prof Per Gunnar Svensson is president of the International Academy for Design & Health 

References
1.
Mann, George J. Toward an international architecture for health practice. Healthcare Design 2007.
2. Gregory B Diette, Noah Lechtzin, Edward Haponik, Aline Devrotes, Haya R Rubin. Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy. Chest 2003; 123.3.941-948.
3.
Mimi M Y TseI, Jacobus K F Ng, Joanne W Y Chung, Thomas K S Wong. The effect of visual stimuli on pain threshold and tolerance. Journal of Clinical Nursing 2002; 11.4.462-469.
4.
Ulrich, R S, Gilpin, L. Healing arts: Nutrition for the soul. In S. B. Frampton, L. Gilpin & P Charmel (Eds),
Putting patients first: Designing and practicing patient-centered care (pp 117-146). San Francisco: Jossey-Bass; 2003
5.
Ulrich, R S. View through a window may influence recovery from surgery. Science 1984; 224.4647.420-421.

Carlo Ramponi, MD, MBA
2007 Managing Director, Joint Commission International
2000 Consultant and Project Director, Joint Commission International
1985 Researcher and Lecturer, Bocconi University, Italy
1984 MBA received from University Luigi Bocconi, Milan, Italy
1965-85 Various senior positions in clinical pathology and general medicine, including Medical Director at Centro Analisi Fleming, Brescia
1975 Medical Degree received from Parma University, Italy



























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