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.

Final design workshop for NICU likened to “speed dating” [Photo Gallery]

Mary Beth Frye, Megan Pollock and nurse Sofiya Lizhnyak participate in NICU simulation

NICU family care coordinator Mary Beth Frye, Megan Pollock and nurse Sofiya Lizhnyak participate in a NICU simulation to test the new design space.

Akron Children’s Hospital’s NICU team began its final design kaizen with an approach that could be compared to speed dating.

The team broke into three small groups that rotated around full-sized cardboard mock-ups that represented patient rooms, medication rooms, team rooms, family and staff quiet rooms, supply and equipment rooms, pod work stations, and remote networking or “touchdown” rooms.

Each group had 45 minutes to review and discuss where every stationary and portable item should be placed in each room.

During a simulation scenario, Dr. Jen Grow and mock patient family test out the design of the new patient rooms

During a simulation scenario, Dr. Jen Grow and Megan Pollock test out the design of the new patient rooms.

The teams took the needs of NICU families into consideration – everything from how to provide coffee and tea service most economically and efficiently to the need for recliners in the quiet room for parents to hold their end-of-life babies.

“It’s been great to be able to give input on everything from the chair position in the patient room to the counter space and cabinets in the bathroom,” said Megan Pollock, a former NICU parent.

In all the rooms, the team discussed the smallest details:

  • How many and what types of seating are required?
  • How many phones and chargers for communication devices are needed?
  • What types of storage work most efficiently in different rooms?
  • Would white and cork boards be useful or compromise patient privacy?
  • What size windows provide the best compromise between visibility, privacy and cost?
  • What’s the best location for the breast milk and formula refrigerator and the meds refrigerator in the medication room?
  • Could crash carts be stored in the medication room?
  • Where is the best place to locate sinks to avoid splashing and possible contamination?
  • Are clutter free counters with storage shelves above the best approach?
  • Who will be responsible for cleaning and stocking items?

After the NICU team agreed on changes, they used simulation scenarios to confirm that they knew where to find what they needed and make sure the newly designed spaces work as planned.

“Participating in the simulations was awesome,” Megan said. “The newborn mannequin made the whole experience feel so real. When I practiced kangaroo care with it, I could feel the heart beat.”

The NICU team will now embark on two years of process refinement during the Critical Care Tower construction, culminating in the move to their new space in 2015.

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.

Simulations help team design most efficient ER

Dr. Gregg DiGiulio examines a mannequin during a simulation to help design the new ER.

A 15-month-old lies in an ER trauma room after being transported by EMS from an adult hospital. Lab results indicate possible kidney failure.

A 6-month-old suffering seizures is being treated in an ER patient room.

A baby has been found not breathing in a bassinette by a babysitter and has been brought to the ER by EMS.

A normal day in Akron Children’s Hospital’s ER?  Not today.

These are 30-minute simulations being played out at the warehouse in Green Township. They’re helping the ER team in its continuing effort to design the most efficient ER, which will be part of the hospital’s new Critical Care Tower.

In previous sessions, the ER team defined equipment needs, room sizes, basic layouts, and the location of support services.

Dr. Mary Patterson is part of the team helping design the new ER and trauma space in the new critical care tower.

This week, ER team members are enacting simulation scenarios created by Dr. Mary Patterson and her staff in the simulation center, to refine the details of the space and determine how it actually works in practice with a patient.

This means fine tuning what’s in the rooms and where everything is placed. Is equipment easily accessed or in the way of staff providing patient care?

ER staff members are assigned roles to play – residents, attending physicians, medical nurses, procedure nurses, recording nurses, respiratory therapists, x-ray techs, anesthesia assistants, observing students, child life specialists, even distraught parents – to evaluate how well the space and equipment work for each member of the team.

The team surrounds the “patients” – mannequins with pulses, eyes that react to light, and breathing and heart sounds – to test the placement and functionality of equipment.

These simulations are videotaped, and with Dr. Patterson leading the debriefing sessions that immediately follow the simulations, team members watch the videos and talk about their own experiences to identify what’s working and what needs to be changed.

As the week progresses and equipment and cart placements are decided, slow-motion simulations will be used to confirm that medications and critical equipment are within the reach of all members of the team, from the tallest to the shortest.  Simulations will also capture patient care at and from ambulance bays.

All of these workshops taking place at the warehouse are part of what’s called a Kaizen, a rapid process improvement event. This will be the last Kaizen meeting for the ER team. Refinements made in this session will be reflected in the completed architectural drawings due by March 8.

Putting the You in NICU

Jordan happy to see his NICU nurse, Betty, at the Kaizen to help design Akron Children’s Hospital’s new neonatal intensive care unit.

Jordan and I attended the mock-up of Akron Children’s new neonatal intensive care unit last month. To be honest I wasn’t sure what to expect. In fact I should have prepared ourselves for a longer stay with more snacks and distractions for the little man.

As usual he was a little distraction himself, however it appeared some of the staff needed a little sidetrack from being there for 2 ½ days and facing 2 ½ more. As we walked through he brought out his little trick of pointing at someone only to have a finger pointed back as he quickly snatched their finger and giggled with that two toothy grin.

The layout of the new floor is amazing. The cardboard layout gave a small glimpse of the size of what our new NICU will look like. The twin rooms were set up for the staff to break into two groups to discuss what they felt would best suit the staff and families.

Some discussions consisted of where a sink should be placed to allow counter space, whether a sliding door should be placed in between two rooms or a regular door with blinds. Another question was about where the linens and trash should be placed to decrease the amount of people who enter the room.

Megs and Jordan participate in discussions about new NICU.

Lots of questions we don’t typically think about when we’re sitting and watching our little ones as they’re being treated. I enjoyed watching the brainstorming take place. They were also gracious enough to ask what I thought as a parent.

The building staff asked where, as a parent, would I want to be if I was going to be discussing “news” about my child. Personally I felt a small conference room would be fine, and if a procedure would need to be done in our room, I would want to sit with Randy in the small common area close by.

After a break we took a pretend tour of what we would see as we entered the floor from the elevator. We considered what kind of greeting we would have and what would be promoted as a warm welcome scene. What would the kids’ area look like? Where should the bathrooms go? (Jordan spoke up that he would like to see kiddy potties that are lower to the ground.)

We also talked about the laundry room and refrigerators that allow families to store their food that they brought from home.

My thoughts wandered to the feeling we have when we enter the hospital’s Reinberger Family Center. I feel a sense of safety and security. It’s a place that allows my shoulders to relax a little and causes me to sigh if it’s ok.

My mind was zigzagging throughout the next night thinking of more ideas I would love to share.

Jordan sits in nurse Betty’s lap.

However, although buildings and facilities can help make you feel like you’re in a great place, what makes me feel like a million bucks are the people. It’s awesome to have a nurse or doctor see you after being away for 16 months and offer encouragement at how well your child looks.

It’s the people who make the experience.

As we entered the NICU reunion last month, we were greeted by the nurse who gave us the encouragement and knowledge about caring for our little peanut. She assisted in teaching Jordan and me about how to get the best nutrition possible through nursing.

As we sat next to his bedside she kept tabs on how Jordan was feeling through watching his monitors and taking care of his roommate. We gazed in awe as she effortlessly transferred him from his isolette to our chest for kangaroo care. There aren’t enough words to express what Betty means to our family.

Dr. Protain with Jordan and Megs at NICU Kaizen.

As we wrapped up our day, we were able to briefly catch up with Jordan’s first girlfriend, Dr. Protain. During our stay, when she made her rounds she would approach Jordan by stating, “there’s my boyfriend.”

I can’t tell you the warmth we felt as she interacted with him 16 months later. It is these types of experiences that makes Akron Children’s Hospital sparkle. I treasure the fact that we’ve had the honor of meeting so many angels through our experience, but it’s comforting to know these heroes put their capes on daily.

Read more about Megs’ and Randy’s journey of raising a child with spina bifida through her blog, Labor of Love.

No kid wants surgery, but here’s to making the process the best it can be

How do we build a same-day surgery center that satisfies the needs and desire of everyone – patients, patient families, doctors, anesthesiologists, nurses and surgical support teams?

As Akron Children’s Hospital moves forward with its plans to build a $200 million critical care tower, teams continue to meet, brainstorm and test out architectural designs in a true-to-scale setting during weeklong Kaizens. Kaizen is a Lean term that refers to improving processes continually by making incremental changes.

Parents Beth Tenda and Judy Doyle participate in the Kaizen to design the new outpatient surgery space.

In September, a team representing outpatient surgery gathered in a warehouse, where cardboard-like walls defined surgical suites, recovery rooms, pre-op areas and other spaces and allowed doctors, nurses and patients to move through their typical day.

As the Kaizen began, several issues were front and center:

  • The need to create the ideal number of surgical suites based on current patient volumes as well as future growth.
  • The need to keep the ORs running as efficiently as possible, taking into consideration the ebb and flow of higher and lower volume procedures, as well as planned and emergency cases.
  • Focus on flow – How much walking will be required for patient families, as well as the doctors and nurses?
  • Movement of supplies in and out of the ORs. Surgical instruments come into the room sterile and the proper equipment must be assembled for each case, whether it’s an ENT procedure, an eye surgery or an orthopedic case.
  • Providing a calm environment that promotes privacy.

As the week began, it felt like this was an impossible task to come up with a floor plan that addressed all of these concerns and made everyone – from the anesthesiologists to the surgeons and the surgical support team – happy.

We were reminded again that Akron Children’s is a dedicated pediatric hospital and that children are not “just small adults.” The team worked to ensure excellent sight lines of patients in the recovery unit design to enhance patient safety.

“Unlike an adult hospital, children in the recovery unit don’t necessarily stay in bed,” said clinical coordinator Tina Sanzone, RN, BSN. “We need to have patients in view to ensure patient safety.”

The team went through phases of anticipation, discouragement and hope as each day welcomed success, frustration and new architectural drawings of the space. Each layout, when constructed three-dimensionally, generated dissatisfaction that the ideal plan still had not been developed.

Until Day Four.

When the exhausted team found their architectural team had worked overnight to meld the best ideas from two of the previous designs, they realized they finally had a winner.

The last design greatly improved patient flow. It offered easy access to storage. Doctors and nurses were not wasting extra steps within surgical suites or between them and other key spaces. The plan built in flexibility for growth and change down the road.

“The translation of design from paper to three dimensions can be eye opening,” said Beth Carr, MSN, MBA, RN, director of Nursing for Surgical Services. “When you see a design on paper, you envision it to work correctly. It’s not until you are actually in the space, and moving within it, that you realize it may not be ideal. The process takes time and patience. When you think there are no options, options present themselves.”

Parents, kids create wish list for their ‘dream’ hospital

In a free-wheeling exchange of ideas, the parents who participated in a focus group to help design Akron Children’s Hospital’s new critical care tower clearly love much about the current facility. They hope to see Akron Children’s culture preserved as it grows bigger.

Parents used phrases like, “comfortable,” “bright,” “warm,” “clean” when asked, “What should be the first impression of Akron Children’s?”

Sarah Sanford said she hopes the new hospital tower will remain a place where “everyone you meet with knows your child.”

Megs Pollock and Jackie Smolinski agreed with that sentiment, adding that they didn’t want the new building to be “too sterile,” or to “look like an airport terminal.” In other words, even if it is big, make it feel small.

Parents attending the session included mothers who had newborns in Akron Children’s NICU as well as those who come to the hospital often with children who have complex healthcare needs.

While the parents talked about what they wanted in the new building, a group of kids were in a nearby room drawing pictures of their “dream” hospital and sharing their own opinions.

While Michelle Ott talked about the importance of having automatic, wheelchair-accessible doors that her daughters could open themselves, 13-year-old Jenna Ott drew a picture of a hospital room with a canopy bed, a “gummy bear” bean bag chair, and lots of pink and purple.

Jenna’s design was conservative compared to other kids who envisioned robots, roller coasters, an ice rink and a beach incorporated into the new hospital.

“I love that kids were invited to this event and that they have a say,” said Michelle.

Jenna has had 20 surgeries so far in her young life and older sister, Alix, who also attended, has undergone more than 50 surgeries. The Ott girls were excited to think that they may actually see some of their ideas in place when the hospital tower opens in 2015.

The parents were also asked what they appreciated about the existing facilities, what they would like to change, and the best way to create a healing environment.

Parents associated healing with kind-hearted, friendly people, serene colors, natural light, music and water.

MaryBeth Fry said NICU moms would get hope from seeing pictures of preemies juxtaposed with pictures of the same children doing well in middle school, high school or college.

Even if the NICU gets bigger – with individual rooms – Fry and the other moms want the new space to balance their need for privacy while giving them the opportunity to meet, develop a support group and maybe even become lifelong friends.

“Research shows that when you reduce stress for parents, you reduce stress for the child,” HKS architect, Rachel Saucier, told the group.

‘Saving lives’ in a mock trauma room

It’s 3 a.m. in the ER when the call comes in. There’s been a car accident. A 16-year-old boy – unrestrained and the driver – is being life-flighted. He is in respiratory distress and has head injuries.

His 10-year-old brother and front-seat passenger is coming by ambulance. His injuries, neck pain and an obvious deformity to the lower body, appear less serious.

The team – a doctor, nurses, a surgical resident, transport team members, staff from lab and radiology, and others – gather in a trauma room. But this trauma room is different. Its walls are made of Falconboard® (heavy duty cardboard) and it’s actually in a 90,000 square foot warehouse where stacks of new automobile tires seem more “in place” than a pediatric medical team.

The mock drill is part of the innovative process Akron Children’s Hospital is using to design its new medical tower, which will include a new emergency department, neonatal intensive care unit, outpatient surgery center and expanded clinical areas.

Leading the mock trauma drill is Laura Pollauf, MD, director of Emergency Services for Akron Children’s Hospital.

“Our goal with this scenario is to really test the size of this room,” said Dr. Pollauf, through a megaphone with the team assembled around her. “When we have a trauma like this, we can have up to 16 people in the room, including the doctor, three nurses, a trauma surgeon, a lab tech, a fellow, child life, a social worker, and the parents.”

During the scenario, the participants pay attention to details. Is the hallway wide enough for a stretcher? Is life-saving equipment in quick reach? Where will the mother enter and how will she be escorted to meet her sons? If the mother is being registered near her children, will this create a bottleneck in the hall?

Jackie Smolinski, a mother of three, including a son with special needs who is well known in Akron Children’s ED, raises the concern that the 10-year-old boy may be traumatized by seeing his older brother undergoing life-saving measures. But Dr. Pollauf suggests that a pull-back curtain could help with that while still allowing the mother to be with both her sons.

Smolinski and five other mothers who serve on the ER design team have also raised issues such as the need for more restrooms in the ER and a larger waiting room, giving Security a stronger presence, and improving overall flow and wait times.

After an informal discussion about the trauma scenario, team members emerge from their cardboard maze ED and return to tables in another location of the warehouse. They will discuss what they liked and didn’t like in the scenario with architects, engineers and construction team.

The goal is to get the design perfect. So when Akron Children’s new emergency department opens in 2015, it will be more than ready to care for two brothers hurt in a 3 a.m. car accident and all other patients who enter its doors round the clock.

Learn more about Akron Children’s building expansion project, called “Building on the Promise.”

Integrated Lean Project Delivery flips the design process

For the past few months, hospital leaders, patient families, doctors, nurses and clinical staff have been meeting regularly with architects, builders and Akron Children’s Lean Six Sigma process improvement team to plan the new patient tower, which is part of a $200 million expansion.

The process, known as Integrated Lean Project Delivery, is expected to:

  • improve productivity
  • eliminate waste
  • enhance the overall patient experience

It’s expected to reduce costly change orders in the construction phase and the project’s overall cost.

“We plan to build flexibility into our design so that we can be prepared for the changing health care environment,” said Grace Wakulchik, chief operating officer. “For example, we are designing our new neonatal intensive care units so they can become pediatric intensive care units or even general patient rooms if our patient volumes and patterns change.”

Akron Children’s Chief Operating Officer Grace Wakulchik

Department teams, in conjunction with the architects, are using small scale models, including paper dolls, to design their floors. Blueprints will be tested in full-scale mock-ups constructed in a local warehouse.

This will allow doctors, nurses and patients to walk down hallways, enter exam rooms and reach for supplies – catching potential problems – well before the real construction begins.

Construction will begin in the spring of 2013 and will be competed in 2015.

The companies assisting Akron Children’s with project management include: