Balancing bricks, bytes and behavior: lessons learned from inpatient wards with 100% single occupancy rooms

Type of the Paper: Peer-reviewed Conference Paper / Full Paper

Track title: Engagement – co-creation, co-design, design and stakeholder management processes

Balancing bricks, bytes and behavior: lessons learned from inpatient wards with 100% single occupancy rooms

Liesbeth van Heel ^1,* and Clarine van Oel ²

¹ Department of Public Health & Program Integrated Buildings, Erasmus University Medical Center, the Netherlands; m.vanheel@erasmusmc.nl ; ORCID 0000-0003-4799-3057

² Department of Architecture and the Built Environment, Delft University of Technology; ORCID 0000-0002-4959-2938

Abstract: The design of a new hospital is typically used as a catalyst for change, redesign and implementation of new work processes to improve health services. Perceived outcomes after relocation may be linked to the success of co-design and stakeholder engagement processes. Especially in striking the right balance between the building (bricks), processes and supporting IT (bytes) and work processes (behavior). Even when stakeholders are engaged in the design that is not to say that their needs will be safeguarded during trade-offs in various phases of decision-making. Furthermore, the time window between engagement and project delivery may contribute to a mismatch in perceived outcomes after relocation. This study aims to gain insight into the possible causes for the perceived mismatches as expressed by ward managers some 12 months after relocation. This was altogether some 6 years after the design of the facility was completed. It will increase our understanding of the complexity of design, construction and transition processes that have to deal with a gap in time between design and use. We adopt an interpretive case study approach in which in-depth interviewing has been combined with an extensive analysis of documents collected over time. We found transformative change requiring an integrative approach to the Bricks and Bytes throughout the whole process of designing, constructing and taking into use, with stakeholder engagement as a key element. Additionally we found Health Care Worker Behavior not well enough considered in a predominantly rational design and implementation process focusing on patient centeredness.

Keywords: post occupancy evaluation, stakeholder engagement, transformation, hospital design

1. Introduction

The planning and design of a new hospital is typically used as a catalyst for change, redesign and implementation of work processes to improve health services and outcomes (Tucker, Hendy, & Barlow, 2014). These projects often include an ambition of more patient centeredness in their care delivery. This comes with the need of encompassing a cultural shift in the project, and not just relying on an improved care environment (Fix et al., 2018). Adding this ambition to change organizational culture by facility and service redesign ideally requires joint optimization of continuously coordinated change, affecting both the social and technical aspects of an organization (Hamilton, Orr, & Raboin, 2008). Ideas about new innovative care models, related to the organizations’ strategic plan and expressed in end-user perspectives must thus already be part of the planning and design process (Elf, Fröst, Lindahl, & Wijk, 2015). The organization’s project goal is transformed from a construction project into a successful transition towards a new, smart hospital environment. Launching ideas to engage in a hospital construction project is thus to be considered a transformative change project, as was the case in a large tertiary hospital in the Netherlands. At the start of this process, in which the first author was involved from the start onwards, the transformative character of the anticipated project was echoed through the ambitions that were first set out. Erasmus University Medical Center (Erasmus MC) wanted to create an innovative care environment to cater for its tertiary care patients, often requiring multidisciplinary care, that would combine ‘high tech’ with ‘high touch’. It had to support care professionals not just in patient care, but also in education and research. And it had to have the ability to utilize its capacities as efficient and effective as possible, e.g. resulting in 100 % single room accommodation, as evidence was already suggesting this would be the optimal environment to support patients and their families, reduce stress, prevent errors and infections etcetera during a hospital admission. Efficient hospital management would be supported by integrated planning and redesign of work processes to support patient pathways, and process supporting IT.

Given the dominant discourse already at the start the project of an evidence-based approach, and having a transformative project goal implies that project success must be measured beyond the factors of time, budget and quality. These factors are most often used in assessing project success in the construction industry. Because transformative change is only to be evaluated after the hospital has been taken into use, such an evaluation is challenging. Moreover, the quality and thus the added value of a healthcare building’s design to its end-users can only be truly assessed and appreciated after the facility is finished and taken into use. And this is seldom done, due to the difficulty of distinguishing between all the variables that change with a hospital relocation, thus changing the context of such an evaluation (Barlow, et al, 2016). Exploring causality is made even more complex as this is the moment where the built environment (the bricks) has become ‘smart’ with its IT- and supporting services (the bytes) in facilitating end-user in using it in the new ways intended (the behavior). To date, only few have included the use of ICT and supportive services in their evaluation of the hospital environments (Hamilton (2008) and Elf et al (2015).

The concept of Bricks, Bytes and Behavior originates from introducing New Ways of Working (NWW) in an office environment, where use of ICT (bytes) is seen as an important enabler for a more flexible use of the work environment (bricks), also leading to new relationships between employees and management (behavior) (De Kok, 2016). And indeed during the recent COVID-19 pandemic this IT-enabled flexibility has served many Health Care Workers (HCW) in continuing their work at home or make a switch to video consultations, finally making ‘digital first’ a common practice (Voss, 2022). Ideally all three elements (bricks, bytes and behavior) are balanced and continually optimized throughout all project phases. Making a shift to 100% single room accommodation can be seen as an illustration of this transformative change in bricks, bytes and behavior. It is known that single occupancy rooms (bricks) present a number of challenges to HCW, such as different relationships with co-workers and patients (behavior), changed perceptions of patient visibility, increased by-the-bed patient care interactions, altered resource allocation and the need for different communication techniques (bytes) (Barlow, Hendy & Tucker, 2016). However, a long lasting process with multiple stakeholders with their own needs and constraints, negotiations and final decision-making can result in mismatches. Such mismatches are expected to become clear once the hospital has been taken into use and daily practices develop.

In the current study, we aim to investigate what mismatches ward managers perceive some 12 months after relocation, and to evaluate to what extent these mismatches can be understood as reflecting conflicting processes originating from the domains of construction (Bricks), or smart ICT technology (Bytes) or working practices (Behavior). In a long lasting process with multiple stakeholders with their own needs and constraints, negotiations and final decision-making these mismatches are bound to occur and may hamper transformative change. In doing so, we focus on the in-patient wards. This study is part of an overarching study to learn lessons from a twenty years design and construction process of a large tertiary hospital in the Netherlands in which transformative change through stakeholder engagement has been mentioned as a major positive factor to successful project delivery (AT Osborne, 2018).

2. Theories and Methods

A practice based, interpretive case-study approach is adopted to deepen understanding of the balance between bricks, bytes and behavior. This case-study is a compelling one for in-depth analysis given its use of temporary organizations, its governance within complex project or program organizations, and its stakeholder and end-user engagement in extended design and transformation projects. It concerns a ‘brown field’ redevelopment on an inner city campus, encountering governmental regulation at several levels and stages, while in size, longevity, cost and phased construction qualifying as a mega-project (Flyvbjerg, 2017).

Fundamental to the approach taken at the project’s start is that the organization’s Executive Board aimed for innovation and transformative change. To this end three main principles were phrased and were made central to the further debates. The first principle was phrased as ‘Thinking differently’ and targeted healthcare delivery in 15 year time. The second principle focused on simultaneously developing work process redesign and was referred to as ‘Working differently’. Then the last principle concerned a new approach to the planning and design of the physical environment (‘Building differently’).

The work process redesign project, starting in 2001 and following an independent course, focused on patient pathways as a way to improve quality of care and patient experience, with the aim to implement improvements straight away. Due to site constrains and the longevity of the construction process in this case study, for the new hospital wards, the redesign input at the time was limited to developing generic principles as a means to inform the design process. Table 1 summarizes for each of the main principles the characteristics of the ward environment that resulted from the negotiation process with project stakeholders. This negotiation processes occurred at different times due to the very nature of the design and construction process of the new hospital. The ‘Thinking differently’ user needs originate from 15-20 years prior to relocation to the new facility. The built environment was co-designed some six years before relocation. Finally, the process targeting the elaboration and implementation of the new, generic work processes started only four years before relocation. The latter process had to incorporate the introduction of a new Electronic Patient Record (EPR)/Hospital Information System (HIS) one year before the relocation, with a second release upon relocation. This ERP/HIS was considered a necessary step to enhance quality of care and business processes, but also to support new ways of working in the new hospital environment.

Table 1: ward characteristics: outcomes of stakeholder negotiations

Evaluation interviews with ward managers were conducted 9-18 months after relocation. A semi-structured interview protocol was followed and addressed topics such as first experiences (good or bad) from managers and their nurses, patient experiences, issues with facilities on the ward and in patient rooms, communication devices and teamwork and the new roles on the ward of facility care worker and pharmacy assistant. Interviews were transcribed and analyzed using ATLAS.ti. From the nine interviews issues were identified where ‘work practice as imagined’ turned out to differ from ‘work practice as done’ (Pomare, Churruca, Long, Ellis, & Braithwaite, 2021). These issues were analyzed as examples of an apparent mismatch or imbalance between bricks, bytes and behavior. In this the time factor of design related decision making and change management approaches was considered as well. Some issues could be investigated further using the extensive project archive at the disposal of the researchers, going back to the development of the projects’ strategic ambitions. Citations as used have been translated from Dutch.

3. Findings

Stakeholders

Table 2 offers an overview of the issues that were mentioned most often during the evaluation interviews. They start with imbalances originating from concepts introduced as part of the service and process redesign. Each issue is related to choices in the built environment, such as standardization and ward size depending on its position within the shape of the building. Some of the ward managers interviewed played a role in the co-designing the new inpatient wards. So they were long-term internal stakeholders. All ward managers were involved in the NWW program. This program designed, again together with stakeholders, the generic work processes, conducted fit-gap analysis with existing ward practices and prepared teams for working in the new environment with the new supporting IT-systems and services. The late introduction of the new EPR/HIS introduced a lot of uncertainty about the process supporting IT end-user could expect at relocation. In addition, different aspects contributing to an overall functioning ward environment at relocation were commissioned from different temporary project teams, with the inherent risk of ownership-issues arising between co-producing partners.

Other stakeholders involved, however, are the Infection Protection and Control team (IPC-team), whose requirements were formulated as part of the briefing process and were subsequently incorporated in the design. The Bytes are represented by initial limitations of the EPR (implemented 11 months prior to the move with a new release on relocation) and for instance the smart room-display (patient name and barcode, directly linked to the EPR). Besides, the Medical Integrated Communication and Information System (MICIS) project developed the IT-support of the new work processes, such as brokering different alarms to the HCW’s mobile device. Building on the patient centeredness ambition, this project also developed a mobile patient alarm. In the column Behavior we note where HCW and visitors reported difficulties in their (work) practice, as brought forward by the ward managers interviewed.

The new wards

Figure 1 offers an overview of the ward lay-out in our case-study. A floor has between 109 and 120 single patient rooms; the floor is divided into five units of 12-32 beds, with two units sharing off-stage office and service areas. As summarized in table 2 the main findings were issues to do with the standardization of ward design and processes and a lack of fit between building design, equipment and intended and actual use. Table 2 also shows that most issues can be related to a combination of bricks, bytes and behavior. In the remain, some findings are elaborated on given their relation to bricks, bytes and behavior according to the perceptions of the interviewed ward managers.

Bricks

The principle of working differently was meant to overcome territory claims from different departments and to ensure generic processes related to the patient’s journey were facilitated in a standardized way, when encountering different specialties during following

.

Figure 1: schematic ward lay-out (used with permission of Erasmus MC and EGM architects)

Figure 2: part lay-out with off-stage office and service/facilities areas (used with permission of Erasmus MC and EGM architects)

care episodes within the same hospital. It was also meant to ensure future flexibility if changes in caseload between specialties would occur, so beds could be redistributed. As a results, the standardized ward design, with units ranging from 12 to 32 rooms (and beds), does not always fit the allocation of rooms on one floor over different specialties. One unit of 32 beds, for instance, can be shared between two different ‘themes’ or clusters of medical departments. Eight beds of this 32-bed unit are used by a different specialism, but are dislocated from the 16 other beds of this specialty. As a consequence this nursing team works on two sides of a service area. When staff shortages force them to close beds, these eight beds are the first to be abandoned, as they are inefficient to staff, especially at nights. So the intended flexibility and collaboration in the physical units does not take place in practice. Organizational or cultural barriers seem to be higher than physical ones, as a ward manager explains: “They call it ‘the island’. (…) At night they are pretty lonely, sitting with 2 nurses on high seats. We invited them to join us, write their reports etcetera. (…) Recently, at times nurses indeed come to sit with my team, but to be honest, these are always the same few nurses that do. (…) They feel uncomfortable to join my team so they rather share their mobile device with us, so they can join their own team further away.”

Little flexibility in use of spaces was found. Where standardization of the wards has provided a ‘lounge’ area for patients and families to sit, a little away from the ward, practice shows that their use is limited due to lack of mobility in certain patient groups. However, wards do not feel comfortable or have not thought about giving it another use, such as a break area for nurses, as we picked up in the interviews as these are were seen as being designated areas for patients and their visitors.

Bytes

Working differently was envisioned as largely depending on high levels of flexibility. This flexibility was thought to be higher in the new hospital because all patient rooms were standardized, single patient bedrooms allowing for flexible, shared used by multiple teams. The EPR/HIS was expected to support this shared use, as a room is a ‘production location’ in a ‘one patient, one file’ system. Here not the building but the IT facilities –thus the Bytes – lack flexibility. As a ward manager explains: “We cannot use a bed from the other specialty. In the EPR/HIS they are fixed and we cannot change this, not for alarms being routed, not for medication that can be ordered. You would expect this to be more flexible.” This shows that IT services are poorly tailored to the stakeholders needs.

To some extent this may have to do with the poor integration of stakeholder needs in designing IT processes during the design of the hospital. This is evidenced by a stakeholder’s remark considering the use of a ‘do not disturb’ notice on the smart room-display. The smart-room display was introduced to establish a real-time link between the EPR and the location of the patient, with the intention to add services to enhance patient control. In order to prevent HCW, or family and friends to walk in when a patient’s privacy and dignity might be implicated due to care or a private conversation, and with patients’ rights in mind, the patient was intended to be able to use the smart-room display for putting up a ‘do not disturb’ notice and control it from the bedside using a tablet. The patient can already use this tablet to choose between several meals, to control the television, indoor climate and housekeeping requests. However, in practice this does not work as a ward manager explained: “It is now considered to use the interactive room displays to indicate a ‘do not disturb’-warning, but we would have to operate the patient’s tablet to change this. These are, to be honest, solutions that are not going to work”.

The example with the EPR/HIS shows that transformative change may not only need involvement of stakeholders but also of specialist knowledge on IT at the intersection of Bricks and Bytes. The example with the smart room displays highlights the importance of involving stakeholders in designing the implementation of IT into the care processes in order to realize transformative change within the Bytes domain. However, there is also evidence of interrelations between Bytes and Behavior. Trust in technological solutions differs between wards, and seems to be related to their prior experience. On a Cardiology ward, where patients are constantly monitored with telemetry equipment that generate alarms at the various decentralized nursing stations and the nurses’ mobile device, the manager reports that the solid and closed door poses no problems¹. Elsewhere nurses rather rely on a ward secretary to manage transportation orders by telephone, bringing or collecting patients from surgery, than trust an alarm generated in the EPR. These administrative tasks still require a very on-stage workplace for the ward secretary, while a more back-office environment had been envisioned for this role. So, differences in maturity in HCW in using intentionally generic support systems are encountered.

Behavior

Although all nursing teams were presented with the same ‘Working differently’ training programs, differences were found in how well prepared teams were. One manager had started to train her team, originating from two different sites, four years prior to relocation. Two managers had to deal with the extra burden of a reorganization at relocation, bringing together nurses with a focus on surgical cases with those with a prior focus on internal medicine. A central message in this Working differently training program was that “The relocation will be like starting a new job in another hospital, but with the benefit of your colleagues all joining you”. However, this central message did not take into account differences between teams, particularly when a new team resulted from a merger of two previously independent locations, or in case of a team that went through a reorganization shortly before the relocation. The need for peer consultation was higher in these teams, but this was obstructed by the new ward design that introduced decentralized nursing station.

HCW were supposed to have their breaks in off-stage break area. Given the open ward structure, the ‘Thinking differently’ message had been the distinction between HCW being ‘on-stage’, visible and accessible in the rooms, corridor and at the decentralized nursing stations, with ‘off-stage’ break facilities available in the back-office are, adjacent to the ward. These break facilities would allow for formal and informal ‘huddles’, for gossiping, celebrations and debriefings, away from prying eyes of patients and visitors. In a later phase ‘Working differently’ labeled these break areas as multi-purpose room, and as part of the office environment. This, for instance, restricted the size of the bin provided in the room, which posed problems after break times. While HCW’s need for team ‘huddles’ was high, not only the distance to the back-office, with a keycard controlled door in between, was felt to be a barrier, but also the new label as part of the office environment. “Early on we had lunch breaks here (ward manager indicates multi-purpose room in the back-office), but it was not tolerated by someone monitoring the use of these rooms [reflecting the design principles that were agreed upon], so now we go downstairs or stay on the ward (on-stage). (…) During the evening we use the decentralized stations or use the pantry [area of mixed use with a coffee machine in the on-stage area]. But then it is awkward if a patient comes in to get a coffee, or a patient is sitting there and three nurses and three juniors come in with their lunch-boxes; so the use of the pantry is not clearly defined.” This example clearly shows that transformative change needs to acknowledge the needs of all main stakeholders. In designing the new hospital there was a strong focus on patient-centeredness and here the needs of the HCW were not recognized to the same extent. This reflects the dominant discourse at the time when the hospital design principles were decided upon. These design principles are at odds with the HCW’s needs to deal with their own privacy and their mental workload, as there was no close-by place for them to have informal encounters with colleagues. They were even using the staircases next to the wards for this purpose. Indeed, as mentioned before, this need was not recognized and accommodated for, and therefore impeding transformative change given the IPC-team’s directive that nurses were not to eat ‘on-stage’, with the exception of meals during evening or night shifts. On the one hand, this example shows the interrelatedness of the Bricks and Behavior domains to realize transformative change. However, it also shows that transformative change requires the organization to adapt its behavior once the Bricks have constrained Behaviors.

Photo 1 and 2: pantry for mixed use and converted to on-stage break-area (photo 1: Erasmus MC, photo 2: Van Heel, used with permission of Erasmus MC)

4. Discussion and conclusion

A guiding design principle in the development of a new tertiary Dutch hospital is the ambition that in designing the new hospital, the work processes were also redesigned, as expressed in the phrasing of “Working differently”. To ensure transformative change, an extensive process of stakeholder engagement was developed and sustained. In a long lasting process with multiple stakeholders with their own needs and constraints,

Table 2 issues and their relation to bricks, bytes and behavior

negotiations and final decision-making can result in mismatches and may therefore hamper transformative change. Such mismatches are expected to become clear once the hospital has been taken into use and daily practices develop. The current study focusses on mismatches but by and large the project has been externally evaluated as a successful project and stakeholder engagement has been highlighted as one of its success factors. However, by investigating what mismatches ward managers perceive some 12 months after relocation, and by evaluating to what extent these mismatches can be understood as reflecting conflicting processes in the domain of construction (Bricks), information / smart technology (to which we refer as Bytes) or working practices (Behavior). This study therefore explored the felt gap between ‘work practice as imagined’ and ‘work practice as done’ (Pomare, 2021). These practices typically reflect decisions originating from a negotiation or trade-off between user needs, as expressed in the different design phases.

The main findings of the current study are two-fold. First, transformative change requires an integrative approach to the Bricks and Bytes throughout the whole process of designing, constructing and taking into use, with stakeholder engagement as a key element. An important asset of the whole process is that the implementation of Working differently started timely. The EPR/HIS can be considered the backbone of the Working differently approach as it allows HCW’s to exchange information independently of their physical location. This is important as one of the drivers to provide 100% single room accommodation is that such allows to break free from traditional ways of working, with all specialisms having their own territory with assigned wards supported by central nursing stations. Transformative change was supported by already integrating new elements of the future working process at the wards. This was done at an early stage, allowing for a revision of the EPR/HIS. The current findings suggest that a further revision of the EPR/HIS is important to realize the intended transformative change. Currently, the inability of the EPR/HIS to fully support Working differently, and to allow for a true flexible and shared use of the patient rooms can be a major reason for a rather traditional organization of specialisms demarcating their own territories. In the presence of specialist territories, it is unlikely for HCW to cross borders, as all groups maintain their own culture. The report of the ward manager shows indeed that HCW behaviors strengthen the distinct territories. One might argue that the late detailing of the Working differently principle, i.e. only four years before relocation, is key, because stakeholder engagement in how to redesign these work processes is then delayed as well. Stakeholder engagement had a strong focus on the Bricks given the emphasis in Table 2 on patient-centeredness in conceptualizing Thinking differently. Both the EPR/HIS and the example of the smart-room display may suggest in hindsight that IT was targeted as the innovative solution to the problems that had to be addressed, at the expense of using stakeholder engagement in the further detailing of what Working differently using IT could be like. An alternative explanation could be that in designing the generic ward, the assumptions that were made about the technological specifications were not closely monitored and addressed in the preparation and implementation phase. An example of the latter would be the expectation that all nurses were to be equipped with a device that could be directly connected to the patient’s device, so that HCW could take over the control of the smart room display if a patient is not capable to do so himself. Indeed, in a recent scoping review on patients’ and nurses’ experiences in all single occupancy in-patient rooms, IT or communication systems are not at all mentioned (Søndergaard, Beedholm, Kolbæk, & Frederiksen, 2021). One could therefore argue that there is an unmet and urgent need to balance Bricks and Bytes to encourage intended behaviors.

The second major finding is that in designing the new hospital, HCW behavior is not well addressed. As suggested before, to some extent this might be so because the dominant discourse emphasized the importance of a healing environment and highlighted patient-centeredness as a common ground in hospital design (Bromley, 2012, Fix et al, 2018). Alternatively, it may also reflect that many professional stakeholders have a background in technology and engineering, and were trained to consider behavior as the result of a rational process, that can be shaped by Bricks and Bytes. However, transformative change does not qualify as a rational process. Especially in healthcare the complexity and related uncertainty for individual actors in transformative change comes with ‘messiness’ and room must be allowed for adaptive actions alongside intentional approaches (Khan et al, 2018). To reach a state of ‘mental ownership’ of the new ward environment HCW will want to adapt their work environment to better suit their needs. From the interviews it became clear that HCW were dissatisfied with the lack of in-ward (on-stage) space to withdraw. Meanwhile, the nearby designated areas for patients and relatives are not used to their full potential. Since the organization enforced a guarded policy on HCW not to take into use these designated patient areas, these areas that could be used to support HCW in their work by offering spaces for informal communications and respite, are now hardly used at all. However, over time, HCW started to claim these spaces while acknowledging the discomfort of the mixed usage of the pantry: “But then it is awkward if a patient comes in to get a coffee, or a patient is sitting there and three nurses and three juniors come in with their lunch-boxes”. Some wards still allow this mixed usage, with the awkwardness attached, while in other wards the pantry has been repurposed as formal break area for HCW, and a glass partition has been installed to provide some acoustic privacy.

To achieve transformative change it is important to balance between the needs of patients and HCW. This evaluation might provide leads to reassign the use of parts of the building. In a related study regarding the flexibility of hospitals during the pandemic we found that the adaptability of HCW might be a major factor determining whether designed-in flexibility can be used to its full potential (Van Heel, Pretelt, Herweijer & Van Oel, 2022). However, the pandemic also learned that the adaptability of HCW requires organizations to better cater to their HCW needs, This evaluation adds in that it shows that the designed-in flexibility can be also used to retrace from too large an emphasis on patient needs at the expense of HCW’s wellbeing.

Data Availability Statement

Not applicable.

Contributor statement

Both authors contributed to the conceptualization of this paper. The study was developed by LvH and CvO, and supervised by CvO. LvH did the data collection, validation and analysis and wrote the original draft. CvO critically reviewed and edited the paper.

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