Anticipate to Participate to Integrate

394 Pages·2016·19.42 MB·English

Anticipate to Participate to Integrate:
Bridging Evidence-Based Design and Human Factors

Ergonomics to Advance Safer Healthcare Facility Design

by

Ellen Taylor

A Doctoral Thesis
Submitted in partial fulfilment of the
requirements for the award of
Doctor of Philosophy of Loughborough University

May 2016

© by E. Taylor, 2016
Intentionally Blank
Abstract
Objective: The primary objective of the thesis is to advance proactive
thinking in designing healthcare facilities for safety by constructing theory to bridge
gaps between evidence-based design (EBD) and human factors/ergonomics (HF/E).
Background: Adverse events are a pervasive issue in healthcare, with causes
and prevention measures under increased scrutiny for the past 15 years. The physical
environment can be an underlying condition of safety and healthcare (HC) facility
design can be seen as a layer of defense in accident causation theory. However, HC
facility design is complicated and complex, and the implications of decisions can be
felt for decades. While architects excel at problem solving, they are not fully versed in
healthcare work tasks, flow, and function, resulting in complex system interactions.
Evidence-based design (EBD) is a process that uses research as a foundation for
decision-making in HC facility design. While the EBD process acknowledges the
importance of system factors, its focus is on understanding specific facility design
interventions on outcomes such as safety, efficiency, quality of care, and satisfaction.
HF/E focuses on humans interacting with a system with a goal of optimizing human
well-being and overall system performance. Although HF/E recognizes the physical
environment as a system component, the ergonomic definition of the environment
lacks clarity and influences are frequently considered at a microergonomic level. In
summary, EBD supports desired outcomes of a system through building design, while
HF/E more often supports desired outcomes of the system through work design.
Methods: The thesis leverages a grant to create a Safety Risk Assessment
(SRA) toolkit for HC facility design using: (1) consensus-based methods to develop
built-environment considerations for falls in HC facility design, (2) a mixed methods
approach to test the SRA in hypothetical scenarios, (3) a mixed methods approach to
test the SRA in real-world scenarios, (4) quantitative and qualitative analysis using an
inductive and abductive approach to construct grounded theory to develop a core
theme and a theoretical framework for proactively considering safety in HC facility
design, (5) an extended systematic literature review to identify additional system
considerations of the organization and people, and (6) established thinking to advance
new theoretical frameworks to achieve the thesis objectives.
i
Results: Two theoretical frameworks are proposed. The first framework,
Safety as Complexity of the Organization, People and Environment (SCOPE) is based
on the Dial-F systems model (Hignett 2013). The evolution includes:
 the definition of the ergonomic environment using building design as the
most stable element of the system, identifying built environment
interventions to mitigate the risk of falls (SCOPE 1.0);
 the addition of non-building design interventions of the system such as
organizational and people-based conditions (SCOPE 2.0); and
 the integration of HF/E design principles to reframe thinking about hospital
falls (DEEP SCOPE).
The second framework evolves from grounded theory constructed through
data from SRA testing proposing safe design as a participatory process to anticipate,
participate, and integrate solutions. A participatory ergonomics framework (Haines
and Wilson 1998) is integrated with a mesoergonomic framework of inquiry (Karsh,
Waterson, and Holden 2014, Karsh 2006) to advance a theoretical framework of
participatory mesoergonomics using the SRA and SCOPE content as inputs over the
course of a HC facility design project to achieve safety.
Conclusion: The gap between EBD and HF/E can be bridged using safety
(falls) as a proactive consideration during HC facility design using theoretical
frameworks. These frameworks address (1) the definition of building design and
design considerations in the HF/E context and (2) integration of the EBD process with
HF/E methods to understand interactions of the system.
ii Preface
Acknowledgements
Portions of this project were supported by AHRQ grant number
R13HS021824. The content is solely the responsibility of the author and does not
necessarily represent the official views of AHRQ. The relationship of the PhD and
grant is found in the preface.
Academic. I would like to thank my academic advisors for their guidance and
support. Through the wonders of Skype and face-to-face sessions in Maryland,
California, Texas, Loughborough, Krakow, Sydney, and Melbourne, Professor Sue
Hignett provided expertise and an immeasurable amount of patience while I
distinguished my work from the grant, grappled with inductive qualitative research,
and chased any number of squirrels. Through critical questions, Dr. Paula Griffiths
enhanced the data-driven approach to the theory development. The many distracting
squirrels (albeit fascinating) served to
expand and solidify my own thinking,
but both Sue and Paula helped me learn
to focus on squirrels of the same color.
Dr. Gyuchan Thomas Jun, my internal
assessor, reinforced the need to present a
complex problem simply. A thanks also
goes to Joel Katz, adjunct professor at
UArts in Philadelphia, who included a portion of my PhD work as a class project
(Graphic Design 307: Design for Understanding). Students Kim Marriott and Holly
Taylor undertook the challenge, and with Joel’s guidance, devised a much improved
visual information system to portray the literature appraisal and the complexity of the
interactions of falls. Laurie Wolf, fellow PGR based in the US, was also able to
lighten the load through our shared, remote, part-time experience.
Professional. The PhD was made possible by the grant project, primarily
supported by the research team at The Center for Health Design (CHD), including Dr.
Anjali Joseph (PI), Dr. Xiaobo Quan, and Dr. Upali Nanda, and project manager
Catherine Ancheta who coordinated the grant volunteers and seminar logistics.
However, it took nearly all of the CHD staff to prepare for and run the seminar for
testing the SRA in 2014. Debra Levin, CHD’s CEO, provided the flexibility to work
and study simultaneously. There were more than 100 volunteers and three healthcare
iii
organizations that participated in the development of the SRA, and I owe gratitude to
all those who allowed their diversity, expertise, and thoughts to become a foundation
for theory development in the PhD.
Personal. Most importantly, this journey would have not been feasible
without the support of Don Knapik, my husband and best friend, who despite hearing
that I would never go back to school, has endured two demanding part-time degree
programs in my MBA and PhD. My appreciation for his support and ‘reset’ button
during my thesis, bonding in the wee morning hours, weekends, and any other time
off, cannot be understated.
“I know I’m in my own little world…It’s okay, they know me here.”
Tea Towel, the Tattered Cover Book Store, Denver, CO

iv Preface
Publications
1. Hignett, Sue, Laurie Wolf, Ellen Taylor, and Paula Griffiths. 2015.
“Firefighting to Innovation: Using Human Factors and Ergonomics to Tackle
Slip, Trip, and Fall Risks in Hospitals.” Human Factors: The Journal of the
Human Factors and Ergonomics Society 57 (7): 1195–1207.
doi:10.1177/0018720815593642.
2. Taylor, Ellen, and Sue Hignett. 2014. "Evaluating Evidence: Defining Levels
and Quality through Existing Methods." HERD: Health Environments
Research & Design Journal 7 (3):144-151. doi:
10.1177/193758671400700310.
3. Taylor, Ellen, and Sue Hignett. 2014. "Patient Safety, Human Factors &
Ergonomics, and Design: The Environment as a Larger-Scale Strategy to
Reduce Falls." International Conference on Applied Human Factors and
Ergonomics (AHFE) Kraków, Poland, July.
4. Taylor, Ellen, and Sue Hignett. 2015. "Silver Bullets or Buckshot? Patient
Falls and a Systems Model in Healthcare Facility Design." 19thTriennial
Congress of the International Ergonomics Association (IEA 2015), Melbourne,
Australia, August.
5. Taylor, Ellen, and Sue Hignett. (in press). "The SCOPE of Falls: A Systematic
Mixed Studies Review." HERD: Health Environments Research & Design
Journal 9 (4).
6. Taylor, Ellen, Sue Hignett, and Anjali Joseph. 2014. "The Environment of Safe
Care: Considering Building Design as One Facet of Safety." Proceedings of
the International Symposium on Human Factors and Ergonomics in Health
Care 3 (1):123-127. doi: 10.1177/2327857914031020.
7. Taylor, Ellen, Anjali Joseph, Xiaobo Quan, and Upali Nanda. 2014.
"Designing a Tool to Support Patient Safety: Using Research to Inform a
Proactive Approach to Healthcare Facility Design." International Conference
on Applied Human Factors and Ergonomics (AHFE) Kraków, Poland, July.
8. Taylor, Ellen, Xiaobo Quan, and Anjali Joseph. 2015. "Testing a Tool to
Support Safety in Healthcare Facility Design." International Conference on
Applied Human Factors and Ergonomics (AHFE) Las Vegas, NV, July.

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Manuscripts Underway
9. Taylor, Ellen, Sue Hignett, and Paula Griffiths. 2016a. "Anticipate to
Participate to Integrate; Thematic Analysis of Testing a Design Tool for
Safety." Manuscript in preparation.
10. Taylor, Ellen, Sue Hignett, and Paula Griffiths. 2016b. "Participatory
Mesoergonomics: Is There an Ergotect in the House?" Manuscript in
preparation.
11. Taylor, Ellen, Sue Hignett, and Paula Griffiths. 2016c. "SCOPE in Design: A
Theoretical Model of Hf/E and Hospital Falls." Manuscript in preparation.

vi Preface
Table of Contents
Abstract ..................................................................................................................................................... i
Acknowledgements ................................................................................................................................ iii
Publications.............................................................................................................................................. v
Table of Contents ................................................................................................................................... vii
Figures ................................................................................................................................................... xiii
Tables ..................................................................................................................................................... xv
Abbreviations ....................................................................................................................................... xvii
Preface ...................................................................................................................................................... 1
A Center for Health Design (CHD) Grant ........................................................................................ 1
Seminar in Designing for Patient Safety ............................................................................... 1
R13 Grant Program for Large or Recurring Conferences ..................................................... 1
Grant Goals .......................................................................................................................... 1
The Center for Health Design Research Team .................................................................... 2
The Case Study Topic: Falls ................................................................................................ 2
Relationship of my PhD to the CHD Grant ...................................................................................... 3
1 Thesis Overview ............................................................................................................................. 5
1.1 Problem Statement ............................................................................................................... 5
1.2 Mind the Gap ........................................................................................................................ 6
Facility Design and HF/E ........................................................................................ 6
HF/E and the Physical Environment ....................................................................... 7
1.3 Contextual Background ........................................................................................................ 8
EBD and Healthcare Facility Design ...................................................................... 8
Safety and Healthcare Facility Design ................................................................... 9
Patient Safety and Hospital Falls ........................................................................... 9
Healthcare Safety and Human Factors ................................................................ 11
Macro, Micro, and Mesoergonomics .................................................................... 13
1.4 Aims ................................................................................................................................... 14
1.5 Objectives and Approach ................................................................................................... 15
1.6 Thesis Structure ................................................................................................................. 17
1.7 Conclusion .......................................................................................................................... 18
2 Filters that Focus the Thesis ....................................................................................................... 19
2.1 Chapter Overview ............................................................................................................... 19
2.2 Filter 1: HC Facility Design ................................................................................................. 19
Design Process .................................................................................................... 20
Implications for ‘Designing In’ Safety ................................................................... 23
vii
Defining Needs ..................................................................................................... 23
2.3 Filter 2: Patient Safety ........................................................................................................ 29
Error and Accident Causation .............................................................................. 29
Work System Design ............................................................................................ 30
Resilience, Safety-I, and Safety-II ........................................................................ 31
2.4 Filter 3: Design Tools and the SRA .................................................................................... 32
2.5 Filter 4: Hospital Falls ......................................................................................................... 33
A Complex and Pervasive Problem ...................................................................... 33
Dial-F: A Systems Model for Falls ........................................................................ 34
2.6 Filter 5: Human Performance—The Body and Brain .......................................................... 35
2.7 Conclusion .......................................................................................................................... 36
3 Design Guidance: Processes, Methods, Evaluation, Tools ...................................................... 37
3.1 Chapter Overview ............................................................................................................... 37
3.2 Aim and Objectives of the Stage 1 Literature Review ........................................................ 37
3.3 Methods .............................................................................................................................. 37
Criteria and Search Strategy ................................................................................ 37
Critical Appraisal .................................................................................................. 38
Thematic Analysis ................................................................................................ 39
3.4 Results ............................................................................................................................... 39
Search Results and Screening Flow .................................................................... 39
Critical Appraisal .................................................................................................. 40
Tools .................................................................................................................... 42
Themes ................................................................................................................ 43
3.5 Discussion .......................................................................................................................... 55
3.6 Limitations .......................................................................................................................... 57
3.7 Conclusion .......................................................................................................................... 57
4 Systematic Literature Review: Hospital Falls (Phase I) ............................................................ 59
4.1 Chapter Overview ............................................................................................................... 59
4.2 Aim and Objectives of the Stage 2 Literature Review ........................................................ 60
The Persistent Challenge of Hospital Falls (Rationale) ........................................ 60
The Complexity of Preventing Falls ...................................................................... 63
4.3 Method: Criteria for Inclusion, Search Strategy, and Screening Flow ................................ 63
Inclusion and Exclusion Criteria ........................................................................... 63
Identification and Selection of Studies ................................................................. 64
Critical Appraisal, Data Extraction and Analysis................................................... 64
4.4 Results ............................................................................................................................... 65
Search Flow ......................................................................................................... 65
viii Preface