Designing the best high-risk delivery area for mom and baby (Video)

When Akron Children’s new medical tower opens in 2015, it will have a labor,  delivery and recovery area for high-risk newborns and their moms.

To ensure the space is designed to provide the best quality and efficiency, our maternal-fetal medicine staff – and parents served by the neonatal intensive care unit at Akron Children’s – participated in a design workshop in October.

The design approach, called Integrated Project Delivery (IPD), brings everyone involved in the project together to seek input before anything is designed.

Getting the details right

During the kaizen to design the new high-risk delivery area, mock scenarios were played out to test the various design concepts.

During the kaizen to design the new high-risk delivery area, mock scenarios were played out to test the various design concepts.

How many corners does a gurney need to turn on the trip between triage and the OR?

What is the best placement of the bed in a patient room to ensure maximum privacy?

Is there a need for refrigeration in the medications room for breast milk?

These and other considerations relating to patient and family comfort and privacy, as well as operational efficiency, represent the final refinements to the high-risk delivery space that will occupy the fourth and fifth floors of the new building.

Dana Nelson

Dana Nelson

“We looked at waiting and reception area flows – that is the family’s first impression,” said Dana Nelson, administrative director of Akron Children’s Maternal Fetal Medicine. “We also wanted to make a very smooth flow for the mothers with as few turns as possible. And we looked for opportunities to bring moms and babies closer together.”

The high-risk delivery space is being designed to accommodate a projected 100 patients annually, but will have plenty of room for expansion as the patient census grows.

The unit will serve pregnancies where the baby, not the mother, is high risk and is expected to need immediate care or surgery after delivery.

Dr. Stephen Crane, director of Akron Children's Maternal Fetal Medicine Division, participates in team discussions about the high-risk delivery space.

Dr. Stephen Crane, director of Akron Children’s Maternal Fetal Medicine Division, participates in team discussions about the high-risk delivery space.

For inspiration, the team, comprised of NICU nurses, representatives from Maternal Fetal Medicine, architects and trade partners, anesthesia, IT and other support services, and former NICU parents, looked at similar high-risk delivery departments at Children’s Hospital of Philadelphia, C.S. Mott and Denver Children’s.

Then they began the now-familiar process, previously used to design the NICU, ER and ambulatory surgery spaces, of mocking up the high-risk delivery space with cardboard as well as actual furnishings and equipment at a warehouse in Akron.

kaizen-team-in-cardboard-seThe mock unit included LDRP (labor-delivery-recovery-postpartum) patient rooms with bathrooms, triage bays, a waiting room and family lounge, C-section/ NICU ORs, a resuscitation room, an ultrasound room, a medications room, an anesthesia work room, consult and conference rooms, a nursery and team work areas.

writing-notes-on-wall-postiDesigned for maximum access, the ORs lead directly into a resuscitation room, where the baby can be stabilized before being moved to the NICU in the adjacent elevator.  Dads can easily move between Mom in the OR and the newborn in the resuscitation room.

When Mom has recovered, she has easy access to her newborn in the NICU via a short elevator ride, instead of being transported from another hospital.

“We also had to talk about those outcomes that aren’t what we hope for,” Nelson said. “We created peaceful, private bereavement space for families.”

Dr. Anand Kantak, director of neonatology at Akron Children's, brings up points about the design concepts.

Dr. Anand Kantak, director of neonatology at Akron Children’s, brings up points about the design concepts.

With team members playing the roles of patients, doctors, nurses and family members, the team continued to move beds, chairs, carts and equipment, until they were sure that the space provided the best patient experience.

At the end of the workshop, team members expressed amazement at the number of details they had to consider in designing a space that was workable for both patients and staff . . .  and the big difference that moving a single door can make in assuring both privacy and efficient treatment.

Where the familiar things are

Abstract design features in the future lobby play into the "things familiar" and backyard ideas. The blue wall represents an abstract fence. The design team is also working on large tree sculptures and a ceiling sculpture element to symbolize a tree canopy of leaves.

Abstract design features in the future lobby play into the “things familiar” and backyard ideas. The blue wall represents an abstract fence. The design team is also working on large tree sculptures and a ceiling sculpture element to symbolize a tree canopy of leaves.

Where does a child’s adventure begin?

The answer: In the child’s backyard.

That answer led to the theme for Akron Children’s new medical tower – “things familiar.”

The idea was to inspire imagination while being comfortable and safe at the same time – like in a child’s backyard.

The theme was a result of a visioning process between HKS Architects and hospital leadership.

The theme meets hospital leadership’s desire to create a place that’s distinctive and serves as a beacon to the community. It also conveys a connection to the natural environment, and inspires creativity and hope.

“A child’s imagination is the most powerful tool we have,” said Becky Baumer, an interior designer at HKS Architects.  “It transports them into another time, another place. It takes them out of their current state and into their perfect future state.  It holds their dreams. It is healing. It is comforting. It is calming. It is playful.  It turns things familiar into magical retreats.”

Each department in the new building will feature a backyard-related design that drives the building’s interior look and feel.

These themes will be reflected in abstract design features appropriate to the departments, and each floor will have an assigned a color, signage and accent walls that fit the themes.

  • ED is “the puddle.” This theme was chosen because water has a calming effect for this high-stress environment. The first floor ED will be blue.
  • The outpatient surgery center is “the sandbox.” Located on the new building’s 3rd floor, outpatient surgery will have a more energetic orange color scheme, reflected in color, texture and pattern.
  • The high-risk delivery area, located on the 4th and 5th floors, will be “a garden,” which is appropriate and restful for this adult audience.
  • The NICU, also occupying two floors (the 6th and 7th), will create the feeling of “a treehouse.”  One floor will be the treehouse at night, using the color magenta and setting the scene for a camp-out or sleep-over. The 2nd floor will be green, to reflect the feeling of spending the day in the tree tops.

“The hope,” Baumer said, “is that as the campus grows and areas are refurbished, this type of theming can be continued.”

Team planning high-risk birth center has 182 collective years of OB experience

Scott Radcliff, of Hasenstab Architects, leads a brainstorming session.

Scott Radcliff, of Hasenstab Architects, leads a brainstorming session.

Last month, Akron Children’s announced that it would dedicate a floor in its new building to high-risk deliveries – a milestone in the hospital’s 123-year history.

This has long been a dream of hospital leaders like President and CEO Bill Considine, as well as the doctors who head up the hospital’s maternal fetal medicine and fetal treatment centers and neonatal intensive care unit.

Now comes the work to make this dream a reality.

Dr. Anand Kantak has long supported the plan to bring high-risk deliveries to Akron Children's as the ideal family-centered care.

Dr. Anand Kantak has long supported the plan to bring high-risk deliveries to Akron Children’s as the ideal family-centered care.

The first steps in planning the new space, which will be on the 4th floor of the medical building already under construction, took place Aug. 5 and 6.

A team of about 20 doctors, nurses, architects, administrators and Lean Six Sigma experts participated in a kaizen (Japanese word for “rapid improvement”) to give key stakeholders a say in how the space is designed.

A high-risk OB patient also participated the first day.

“Delivering babies on our campus may be uncharted territory for us, yet the doctors and nurses in this room have a collective 182 years of experience delivering babies at other hospitals,” said Lisa Aurilio, vice president for patient services and chief nursing officer.

Chief Nursing Officer Lisa Aurilio has also participated in kaizens for the ER and NICU.

Chief Nursing Officer Lisa Aurilio has also participated in kaizens for the ER and NICU.

The plan is to deliver approximately 100 babies per year when prenatal diagnosis determines the baby to be at risk and in need of immediate medical intervention by pediatric surgeons or other specialists upon birth.

This would include babies with congenital heart and neural tube defects, diaphragmatic hernias, and abnormalities that may affect the airway.

The team began by creating a vision statement for the new center. This was done by participants writing responses to prompts like, “I see…”, “I hear…”, “I think…” and “I feel….”

The input of the team members suggest they want to create an environment that's inviting, comfortable and focused on the highest quality of care.

The input of the team members suggest they want to create an environment that’s inviting, comfortable and focused on the highest quality of care.

Each team member was given 5 blue and 5 red dots to place on photos of the interiors of other birthing centers across the country. The exercise indicated the team is partial to soft rather than bright colors.

“They steered away from primary colors and starkness in favor of wood tones, a spa-like feel and interiors that convey home and comfort,” said Sherry Valentine, a project leader for Akron Children’s Mark A. Watson Center for Operations Excellence.

Sherry Valentine, Lean Six Sigma deployment leader, facilitates a group session.

Sherry Valentine, Lean Six Sigma deployment leader, facilitates a group session.

Other activities focused on issues of patient experience and staff work flows.

They looked at the proximity of operating rooms to patient rooms, how many steps doctors and nurses have to walk, storage space, the size and comfort level of the patient rooms, and the various “points of entry” for patients.

While most of these deliveries will be scheduled through maternal fetal medicine, the team also has to plan for the unexpected, including patients arriving via transport, 911 ambulance arrivals, and even the occasional “walk-in” mother-to-be in labor.

Jennie Evans, a registered nurse and medical planner with HKS Architects, offers insight.

Jennie Evans, a registered nurse and medical planner with HKS Architects, offers insight.

The team will make key decisions for the public/shared spaces, such as the waiting rooms, 3 ORs for C-sections, and 6 labor/delivery/recovery/postpartum rooms, which must also flexible enough to become 2 intensive care rooms and an isolation room, if needed.

Several participants talked about how the team “gelled” instantly and how they feel privileged to have a role in a history-making venture for Akron Children’s.

Drs. Melissa Mancuso and Stephen Crane are two of Akron Children's high-risk obstetricians.

Drs. Melissa Mancuso and Stephen Crane are two of Akron Children’s high-risk obstetricians.

“We are all very invested in this,” said Dr. Stephen Crane, director of maternal fetal medicine. “We have dreamed about this for years. It’s the right thing to do for our patients.”

Dr. Melissa Mancuso, co-director of the fetal treatment center, says the ability to perform high-risk deliveries will, over time, enable Akron Children’s to offer new treatment options, such as laser therapy for twin-to-twin transfusion syndrome, ex utero intrapartum treatment (EXIT) procedure, fetal therapy for cardiac conduction abnormalities and in utero release of amniotic bands.

“Of course the best reason for doing this is it keeps moms with their babies and keeps families together under one [hospital] roof. You can’t put a value on that,” said Dr. Mancuso.

That’s not to say the process will be easy.

“The most challenging aspect of this for our hospital is thinking beyond babies and children as patients,” said Aurilio. “Now mothers will be our patients as well, and that has implications for everything we do from insurance contracts to medical coding to laboratory procedures.”

How will healthcare look in 20 years? That would be nice to know as we build now

Dr. David Chand talks with Dr. Emily Scott, a pediatric ED attending physician, during the August kaizen to design the new ER.

As Akron Children’s Hospital moves forward with its $200 million campus expansion, a crystal ball would come in handy.

With health care reform, changing demographics, and other uncertainties, our goal is to build flexibility into our design in every way possible. We can make educated guesses regarding future patient volumes and acuity, reimbursement levels, the always-changing technology and best practices for care, but they are just that – educated guesses.

The kaizen process is a group effort.

The first phase of the plan includes a critical care tower to be built on Locust Street, west of our main hospital. The tower will include a new emergency department, neonatal intensive care unit and outpatient surgical suites. A new parking deck, which will connect to the tower, is already under construction. Later projects include an expansion of the Ronald McDonald House of Akron and additional space for clinical programs.

Akron Children’s is using a forward-thinking design process called Integrated Lean Project Delivery (ILPD), which has brought all stakeholders – physicians, nurses, parents, and staff – together with the architects and engineers to design the new space efficiently and with the best possible patient experience in mind. The guiding principles echo back to the hospital’s original promises of:

  • Treating each child as if our own,
  • Treating others as we would want to be treated, and
  • Turning no child away regardless of ability to pay.

Using this process is a natural evolution for Akron Children’s, which began to embrace the Lean Six Sigma process improvement principles when it created the Mark A. Watson Center for Operations Excellence in 2008.

I have been most closely involved with the team designing the emergency department, which was built to serve 45,000 patients annually but has been serving closer to 60,000 in recent years.

Moving through the design process, we held several architect-led meetings, including a week-long “kaizen” in a local warehouse. Using sturdy cardboard for walls, we were able to test true-to-size floor designs and the functionality of the space by wheeling a patient down a hallway, measuring the time needed to get an x-ray, and counting the steps a nurse takes when reaching for supplies.

We have tested various ED scenarios, including a common case of asthma, a trauma, and a teen having a mental health crisis. A pediatric ED is a busy place and we have sought the input of other hospital professionals who provide services there, including our social workers, dietitians, chaplains, transport team members, pharmacists, lab and radiology technicians, and security and housekeeping staff.

Testing patient care flow during a kaizen to design the new ER.

We studied data, such as our average daily census and length of stay, and created “current state” and “future state” value-stream maps, which quantify all the employees, functions, time and costs that follow a patient from arrival to discharge.

Some surprisingly low-tech supplies such as Post-It Notes, yarn, masking tape, and paper cut-outs have been employed to capture ideas and study work flow.

The goal is to catch design flaws early, reduce the number of change orders and, of course, solve problems before it is too late to make changes.

We learned a few things early on. We want separate ED entrances for ambulances and families bringing children on their own. We want as much standardization as possible to reduce the risk of error. And we want rooms to be universal – able to change in function by simply moving equipment in and out.

The parents on our team told us they hope for improved way-finding and easy check-in. A good sense of safety and security is also a top priority. We were reminded that they often come to the hospital with baby carriers, diaper bags, strollers and siblings in tow and few pediatric ED visits are ever planned. The input they have given us has been invaluable.

Construction will begin this spring, with completion scheduled for 2015. We can only wonder what changes we will see in health care by the time the doors of our new critical care tower officially open.

Dr. David Chand is a pediatric hospitalist and member of Akron Children’s Hospital’s Mark A. Watson Center for Operations Excellence.