The SCOPE of hospital falls: a systematic mixed studies review

Purpose: This systematic mixed studies review (MSR) on hospital falls is aimed to facilitate proactive decision-making for patient safety during the healthcare facility design. Background: Falls were identified by the Centers for Medicare & Medicaid Services (CMS) as a non-reimbursed hospital acquired condition (HAC) due to volume and cost, and additional financial penalties were introduced with the 2014 US hospital acquired condition (HAC) reduction program. In 2015, a Joint Commission alert identified patient falls as one of the top reported sentinel events, and the Occupational Safety and Health Administration (OSHA) added slips, trips, and falls as a focus for investigators' healthcare inspections. Variations in fall rates at both the hospital and the unit level is indicative of an ongoing challenge. The built environment can act as a barrier or enhancement to achieving the desired results in safety complexity that includes the organization, people and environment (SCOPE). Methods: The systematic literature review used MeSH terms and key word alternates for hospital falls with searches in MEDLINE, Web of Science, and CINAHL. The search was limited to English-language papers. Results: Following full text review, 27 papers were included and critically appraised using a dual method mixed methods critical appraisal tool. Themes were coded by broad categories of factors for organization (policy/operations), people (caregivers/staff, patients); and the environment (healthcare facility design). Subcategories were developed to define the physical environment and consider the potential interventions in the context of relative stability. Conclusions: Conditions of hospital falls were identified and evaluated through the literature review. A theoretical model was developed to propose a human factors framework, while considering the permanence of solutions

Silver bullets or buckshot? Patient falls and a systems model in healthcare facility design

Falls are associated with increased length of stay in hospitals and higher healthcare costs connected to additional care, discharges to institutional care and litigation claims. Under current US reimbursement programs, organizations are penalized for hospital-acquired conditions, including falls with injury not present on admission. This paper presents the results from a systematic mixed methods literature review on the correlates and interventions for patient falls. While the review is focused on conditions of the physical environment, these must be considered in the context of organizational and people-based factors to fully address the system complexity. A model for systems integration is proposed. Practitioner Summary: Healthcare organizations continue to struggle with preventing patient falls. Because of the multifactorial contributions to fall risk, falls reduction programs include multiple solutions with no ability to quantify the effectiveness of any particular component, and yet, the question is always asked, “What really worked?” Rather than seek silver bullets, we should establish frameworks that account for the interactions within the system that also a proactive approach to healthcare facility design

The environment of safe care: Considering building design as one facet of safety

Patient safety is often considered in a behavioral context – what can someone do differently to improve outcomes? However, as a complex system of interactions, patient safety is better advanced through a systems thinking lens of human factors and ergonomics (HFE). While HFE is sometimes considered in three domains: physical, cognitive, and organizational, research in the area of the design of the physical environment is often limited to products, equipment and furnishings to accommodate a diverse population of users. With an increased focus on reimbursement related to patient safety as part of healthcare reform, organizations are becoming more aware of their own shortcomings and grappling with solutions to improve performance – typically people and processes. Yet the influence of the built environment, the space in which people work and are cared for , can act as a barrier or enhancement to achieving the desired results– physically, cognitively, and organizationally. Latent conditions of the built environment can contribute to hazards and risk within the system and using Reason’s Swiss Cheese Model can also become an additional layer of defense. A consensus-based safety risk assessment (SRA) design decision tool is being developed to address these built environment latent conditions funded through a three-year grant from the Agency for Healthcare Research and Quality (AHRQ)

Embedding human factors & ergonomics in healthcare with building design at the centre of the system

Background: Risk factors for patient slips, trips and falls (STF) have been identified and reported since the 1950s and are mostly unchanged in the 2010s. The prevailing clinical view has been that STF events indicate underlying frailty or illness and so many of the interventions over the last 60 years have focussed on assessing and treating physiological factors (dizziness, illness, vision/hearing, medicines) rather than designing interventions to reduce risk factors at the time of the STF. Purpose: To use a theoretical model for HFE (DIAL-F) and a comparison with occupational STF risk management to discuss patient STF interventions. Methods: Three case studies are used to discuss how HFE has been, or could be, applied to STF risk management as (1) a design-based (building) approach to embed safety into the built environment; (2) a staff (and organisation)-based approach; and (3) a patient behaviour-based approach to explore and understand patient perspectives of STF events. Results: The results from the case studies suggest that there will be benefits from taking a as HFE approach similar to other industries, i.e. a sustainable design intervention for the person who experiences the STF event - the patient. The DIAL-F model supports a change in bedside interventions from a passive model of providing care and treatment (analogous to a production line with inanimate components) to an active model representing independent functional activities with changed physical, cognitive and behavioural capabilities. The challenge is to design inclusive interventions to benefit a range of patients that do not introduce barriers or problems for staff and other system stakeholders. For example poor balance linked to rising from a chair might be assisted by building and technology design solutions, or not using an out of reach assistive device could be addressed by providing accessible equipment and timely assistance. Conclusions/implications: As over 70% reported patient STF are un-witnessed and research indicates there are benefits from retaining mobility associated with continence, cognitive function and pressure care there is an argument to design STF interventions to support patient mobility and autonomy. Rather than continuing to fight this seemingly intractable problem with complex packages of care, we suggest it is time to look proactively at this problem with an HFE approach to facility design and other interventions that include the perspective of all the stakeholders

Testing a tool to support safety in healthcare facility design

A Safety Risk Assessment is included in the 2014 Faculty Guidelines Institute (FGI) Guidelines for the Design and Construction of Hospitals and Outpatient Facilities, however, tools to support this requirement do not exist. This paper presents continued development of a Safety Risk Assessment (SRA) toolkit to be used proactively during the design of healthcare facility projects. Following content development, the tool was tested at three project sites and through hypothetical scenarios in an interactive testing process engaging expert panels. The testing revealed tactical considerations (content clarity, redundancy, etc.) and strategic aspects (themes related to use) for finalizing the tool. © 2015 The Authors. Published by Elsevier B.V. Peer-review under responsibility of AHFE Conference

Firefighting to innovation: using human factors and ergonomics to tackle slip, trip, and fall risks in hospitals

Objective: The aim of this study was to use a theoretical model (bench) for human factors and ergonomics (HFE) and a comparison with occupational slips, trips, and falls (STFs) risk management to discuss patient STF interventions (bedside). Background: Risk factors for patient STFs have been identified and reported since the 1950s and are mostly unchanged in the 2010s. The prevailing clinical view has been that STF events indicate underlying frailty or illness, and so many of the interventions over the past 60 years have focused on assessing and treating physiological factors (dizziness, illness, vision/hearing, medicines) rather than designing interventions to reduce risk factors at the time of the STF. Method: Three case studies are used to discuss how HFE has been, or could be, applied to STF risk management as (a) a design-based (building) approach to embed safety into the built environment, (b) a staff- (and organization-) based approach, and (c) a patient behavior–based approach to explore and understand patient perspectives of STF events. Results and Conclusion: The results from the case studies suggest taking a similar HFE integration approach to other industries, that is, a sustainable design intervention for the person who experiences the STF event—the patient. Application: This paper offers a proactive problem-solving approach to reduce STFs by patients in acute hospitals. Authors of the three case studies use HFE principles (bench/book) to understand the complex systems for facility and equipment design and include the perspective of all stakeholders (bedside)

Evaluating evidence: Defining levels and quality using critical appraisal mixed methods tools

Evaluating evidence for the built environment is not easy, and many professionals struggle with the challenge of identifying the best available research. This article outlines the current state of science for evaluating evidence in healthcare design, drawing on previous discussion articles in this journal and introducing a Mixed Methods Appraisal Tool (MMAT), which can be used by professional designers to evaluate research evidence for healthcare design. Two case studies are provided to illustrate the use of the MMAT with an evidence levels algorithm