A research study of two existing infusion centers informs the planning of a new Cancer Center.
First, the bad news: The National Cancer Institute estimates that nearly 40 percent of men and women living in the U.S. will be diagnosed with cancer some time in their lives. However, there is much good news on the cancer front. Advances in treatment—including chemotherapy, targeted therapy, surgery, and radiation therapy—have translated into significant gains in survival rates for cancer patients.
Infusion centers are an important setting in which patients receive life-saving cancer treatment. According to the Centers for Disease Control and Prevention (CDC), approximately 650,000 U.S. cancer patients receive chemotherapy in outpatient oncology centers, or clinics, each year. Understanding how the design of infusion centers can influence care delivery is important to improve the patient and staff experience.
For example, for a new infusion center within a new Cancer Center on a regional medical campus in the eastern U.S., the healthcare organization and design team began the planning process by studying two existing infusion centers with different layouts on the campus, focusing on staff workflow and satisfaction and implications for future designs.
The first unit, designed in the mid-1990s, in the main hospital is a compact open bay design. The 3,220 SF infusion center contains 19 infusion chairs (approximately 153 DGSF per chair), and two private bed treatment rooms. Privacy curtains visually separate patients, but they most often remain open during treatment sessions.
The second unit, opening in 2015 in the adjacent Medical Office Building, is a semi-private bay design. The 5,720 SF infusion center includes 21 three-sided infusion bays (approximately 260 DGSF per chair), and one private treatment room. Infusion chairs are separated by partial walls, in addition to privacy curtains at the foot, which are partially closed providing visual privacy between patients without obstructing visibility from the nursing station.
Both centers have two nursing stations.
Several different techniques were used to compare information about staff workflows and staff and patient satisfaction in the two units.
- Gemba walks enabled firsthand observation and analysis of existing workflows, pain points, and major work arounds, as well as processes that worked well and supported flow.
- Nurses working in both infusion centers were shadowed as they went about their workday. Observers recorded nurses’ locations on the unit, time spent, and activities performed for a total of 34 hours. Shadowing was also used to assess the process of medication delivery on each unit.
- Surveys were distributed to staff and patients to gauge satisfaction with the infusion centers. Staff questions included satisfaction with access to patients and other staff, perceptions of patient privacy, communication and collaboration, and the delivery of medications. Patient questionnaires also asked about satisfaction with design elements, as well as satisfaction with wait time, privacy, staff surveillance, and interactions with staff.
Nurse Activities: Where and What
Nurses working in both the open bay and semi-private layouts spent similar amounts of time, overall, in infusion bays, nursing stations, and traveling on the unit. However, differences in the number of times nurses visited the nursing station were observed. Nurses in the open bay design visited the nursing station 27 percent more frequently than nurses in the semi-private design.
A closer look at what nurses were doing while at the nursing station revealed a different workflow for nurses in the open bay layout. Because the nursing station in the open bay design contained the unit’s only handwash sinks, nurses visited the nursing station more frequently compared to nurses in the semi-private layout.
- Locate hand-wash sinks outside nursing stations and immediately adjacent to treatment space to improve workflow and decrease the risk of cross-contamination.
- Provide adequate numbers of sinks per infusion bay at a ratio of one hand-wash sink to every four patient stations.
- Placing sinks outside, but adjacent to infusion bays, results in greater flexibility for future redesign.
Satisfaction with Infusion Bay Design
Both staff and patients reported lower overall satisfaction in the open bay design compared to the semi-private design.
While staff in both the open bay and semi-private designs were dissatisfied with the amount of space to perform tasks—available work surfaces/countertops, and access to medical equipment—levels of dissatisfaction with these aspects were higher among open bay staff. Additionally, patients perceived more clutter in the open bays than in the semi-private bays. Smaller infusion bay spaces likely account for these differences—35 NSF in the open bay compared to 77 NSF in the semi-private bay design.
An interesting tension between patient visibility and staff privacy emerged in the open bay design. Staff in the open bay layout enjoyed maximum visibility of patients (95 percent), while visibility was more limited in the semi-private design (69 percent). Increased visibility in the open bay also applied to staff access in that patients and visitors had better access to staff in the open bay design. As a result, increased staff communication with patients and visitors was observed in the open bay layout. However, staff working in the open bay design were less satisfied with their ability to concentrate without distraction and maintain speech and visual privacy.
- Size infusion bays in accordance with prototypical recommendations and FGI Guidelines (approximately 9’ x 9’ SF) to ensure adequate space to perform tasks.
- Provide work surfaces within bays, near patients, with dedicated space for infusion preparation, computer work, and trash receptacles.
- Balance the need for visibility and privacy among both patients and staff with partial walls and a combination of clear and opaque glass.
Informing the New Design
With these insights from the pre-occupancy research, interactive meetings and prototype mock-ups, HGA and the oncology staff developed fundamental concepts for the new 60-bed Infusion suite that will be part of a large multidisciplinary Cancer Center.
The infusion suite is divided into five pods—four for chemotherapy and one for other types of infusions. Each pod includes 10 semi-private infusion bays, two private treatment rooms, and an infusion lounge. The 84 SF infusion bay is equipped with a dedicated work surface, storage for efficient medication preparation and administration, and EMR charting. Handwash sinks located immediately adjacent to the treatment bays—seven sinks in each pod—will provide easy access to hand hygiene stations.
Partial walls surrounding the centralized nursing station in each pod are intended to facilitate concentration, reduce distractions, and improve privacy while maximizing patient visibility and staff collaboration. The infusion lounge, an open space to which patients may bring a portable infusion pole, offers an option for patients to socialize or participate in art therapy activities. An embedded pharmacy space in addition to dedicated pharmacy workstations in each pod facilitate staff collaboration and ensure safe and efficient medication preparation and delivery.
The new Cancer Center—designed to support the mind, body, and spirit of the patient—is scheduled to open on the same campus in 2020, replacing the existing infusion centers and clinics. The Cancer Center will include infusion, exam, retail, imaging, radiation therapy, and supportive wellness programs.
Future Post-Occupancy Evaluation
After the new infusion center has been operational for six to nine months, the research team will employ the same data-collection techniques used to establish baseline findings in the two previously occupied centers to gather comparison data. The post-occupancy evaluation will generate important information about the success of the new infusion center, thereby informing future infusion center designs that better meet the needs of cancer patients and staff charged with providing quality oncology care.
Read More . . .
For more information, read “The Impact of Infusion Center Layout on Workflow and Satisfactions in Two Cancer Infusion Centers: A Case Study on Staff and Patients” in Health Environments Research & Design (HERD) Journal.
Note: For full access to the HERD article, please contact KFreihoefer@hga.com.
About the Authors
Kara Freihoefer, PhD, is Director of Research at HGA.
Nancy Doyle, AIA, is Senior Medical Planner at HGA.