Getting it right: Simulation-informed healthcare design

By: Christopher Hicks, MD, MED, FRCPC

In a healthcare system hungry for additional capacity, the desire for more can drive decision-making, without considering if more translates to better. At St Michael’s Hospital in Toronto, ON the design for a new trauma bay included expanding from two to three stretchers, ostensibly to care for 50% more critically injured patients at any given time.

Added capacity has advantages but presents challenges as well, many of which are difficult to see. These latent hazards are threats to patient and provider safety that aren’t easily identified until they create a problem, which carries the potential for adverse events and harm. Major trauma patients are cared for by a team of more than ten providers, may have multiple injuries presenting multiple priorities, and often require critical and time-sensitive interventions. Given a finite amount of space, would an additional stretcher help or hinder?

How do you solve a problem when you don’t know that it exists?

Simulation involves the re-creation of real-world events. Using a suite of tools ranging from table-top exercises, patient actors, and sophisticated computer-controlled human mannequins, simulationists craft scenarios that participants then work through as if they are involved in a real event. The resulting deep activation and engagement is then leveraged in a subsequent debriefing session, where skilled facilitators walk back through the scenario, asking curious questions and generating rich data and feedback.

Rather than training individuals and teams, simulation-informed clinical design makes the system and space the unit of analysis:

  • Scenarios are designed to “crash test” common clinical scenarios and weed out latent hazards
  • Debriefing sessions gather information on how the system, space and clinical logistics functioned or failed to function
  • Simulations are video and audio recorded, allowing for subsequent review of movement tracking, “hot zones” (locations where providers tend to congregate or dwell) and bump analysis (how often do team members bump into equipment, or into one another)

The results of this process are impactful in two distinctive ways:

  • The systematic and reproducible nature of data gathering helps to codify and quantify known challenges that can be used to drive meaningful design interventions: Data is a more powerful tool than anecdote
  • Simulation-informed clinical design shines light on safety hazards that would be impossible to see, because the team is not looking for them

Less may actually be more

We used simulation-informed clinical design to put our new trauma bay through its paces. Turns out, the crowding of three stretchers created a series of negative trade-offs and limited the ability to deliver safe and timely care. What followed was a re-working of the space and design, with a two stretcher steady state with the ability to flex up to three if necessary, clear floor markings to preserve the circle of care around the patient’s head, neck and torso, and clinical logistics to support bedside critical care procedures.

Ultimately, you can’t see what you don’t look for. Simulation-informed clinical design harnesses the collective knowledge and engagement of care providers to mitigate danger and drive innovation, in ways that no planning meeting ever could.

Christopher Hicks is an emergency physician, trauma team leader, simulation specialist and principal at Advanced Performance Healthcare Design. NORR and APHD are collaborating to rethink, recalibrate and reimagine the design process of healthcare facilities and spaces through simulation to inform the final architectural design.