Safe Environment

How can a health service environment best support the provision of safe and high-quality care for all patients?

Through the 'safe environment' concept – a component of the National Safety and Quality Health Service Standard on Clinical Governance.

The Four Focus Areas of a Safe Environment

1. Fit for Purpose

The health service environment, including all facilities, plant and equipment, should be fit for purpose. These elements must be kept in good working order to limit the occurrence of accidents and assure patient safety (Australian Commission on Safety and Quality in Health Care 2017).

What does a facility ‘unfit for purpose’ look like? Examples of facilities that made headlines this year:

• A hospital in Wales (UK) was deemed ‘not fit for purpose’ due to the fast-growing risk of transmission of infection detected (BBC News 2019).
• A highly specialised cancer centre in London was deemed unfit for purpose as a result of out-of-date equipment; a lack of adequate expertise among staff; and the dilapidation of the building’s exterior (Campbell 2019).
• A Kalgoorlie hospital was deemed unfit to treat patients with mental illness in a report that called it ‘the worst facility in the State (Western Australia)’ as a result of staffing shortages; inadequate infrastructure; delays in patient transfers; and the use of chemical restraint during delays (Moussalli et al. 2019).

2. Design

Optimum design is much more than aesthetics. Good design can reduce the potential of unwanted events. Design considerations include ensuring adequate lighting is present in areas where medicines are dispensed; or by choosing surfaces that are easy to clean and disinfect (Australian Commission on Safety and Quality in Health Care 2017).

Research into hospital design indicates that, when guided by scientific research, environmental design can positively influence the healing process (Ulrich et al. 2010).

Effective design can directly result in quantifiable psychological improvements, particularly noticeable in areas such as:

• Overall patient satisfaction;
• Increased feeling of safety for hospital staff and patients;
• Reductions in:
• Patient aggression; and
• Staff anxiety.

(Theodore 2016)

The term for design considerations that aim to improve healthcare through architecture is ‘evidence-based design’. It isn’t hard to see how thoughtful design could improve the hospital experience, with many modern facilities moving away from the typical noisy, chaotic and dark hospital environments of old, which only further intensifying patient stress (Berry et al. 2018).

3. Patient Experience

Having clear directions and signage can help patients locate the services they need. Patient comfort and experience of care can be improved through the correct use of furnishings, colour, artwork, light and sound (Australian Commission on Safety and Quality in Health Care 2017).

‘Wayfinding’ is the term given to the ability of hospital staff, patients and visitors to navigate their way through a healthcare facility with ease. Effective wayfinding results in staff spending less time directing people, and a better patient experience overall (NSW Health 2014).

Wayfinding improvements include a combination of the following elements:

• Building and campus design (effective planning);
• Wayfinding strategy (requiring an organisation-wide, coordinated approach);
• Wayfinding systems (interior design, landscaping, signs, printed and digital information, lighting, and art).

(NSW Health 2014)

4. Reduce Unnecessary Stimulation

Well-designed facilities can assist clinicians to provide the correct amount of engagement or stimulation for patients who have mental health issues. By reducing unnecessary stimulation, these spaces can also simplify the environment for patients who have cognitive impairment (Australian Commission on Safety and Quality in Health Care 2017).

The environment should be designed in a way that minimises stimuli that is not helpful to patients, e.g. clutter and posters in the facility. Audio stimuli can also be reduced, e.g. through the use of sound-absorbing ceilings, walls and flooring; and reduced equipment noise where possible (Berry et al. 2018).

Further Guidelines to Meeting the NSQHS Clinical Governance Standard

The health service organisation:

1. Increases safety and quality of care through implementing effective environment design and by maintaining fit-for-purpose buildings, plant, equipment, utilities, devices and other infrastructure.
2. Pinpoints areas in the facility with a greater potential for unpredictable behaviours and develops strategies to minimise the risks of harm for all patrons; it also grants access to calm, quiet environments when clinically required.
3. Improves access to services and facilities by providing signage and directions that are easily understood and fit for purpose.
4. After-hours patient admission has processes that allow flexible visiting arrangements to meet patients’ needs and preferences (when it is safe to do so).
5. Provides an environment that is welcoming and acknowledges the importance of the cultural beliefs and practices of Aboriginal and Torres Strait Islander people.

(Australian Commission on Safety and Quality in Health Care 2017)

Further Reading / Additional Resources

• Australian Commission on Safety and Quality in Healthcare 2017, National Safety and Quality Health Service Standards, 2nd Edition: https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf
• Roger Ulrich’s 2010 paper on research-influenced hospital design: https://journals.sagepub.com/doi/pdf/10.1177/193758671000400107

References

• Australian Commission on Safety and Quality in Health Care 2017, National Safety and Quality Health Service Standards, 2nd ed. ACSQHC, Sydney (NSW), viewed 24 October 2019, https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf
• BBC News 2019, Wrexham Hospital Isolation Facilities ‘Not Fit for Purpose’, BBC News, viewed 25 October 2019, https://www.bbc.com/news/uk-wales-49620621
• Berry, L and Hamilton, K 2018, ‘How to Build a Better, Safer, More Welcoming Hospital’, The Conversation, viewed 25 October 2019, https://theconversation.com/how-to-build-a-better-safer-more-welcoming-hospital-98532
• Campbell, D 2019, ‘Neglected NHS Cancer Hospital is Unfit For Purpose, Says Report’, The Guardian, viewed 25 October 2019, https://www.theguardian.com/society/2019/oct/03/mount-vernon-nhs-cancer-hospital-neglected-should-be-closed-report
• Moussalli, I and Stevens, R 2019, ‘Kalgoorlie Hospital Labelled Unfit to Treat Mental Health Patients’, ABC Goldfields, viewed 25 October 2019, https://mobile.abc.net.au/news/2019-01-24/kalgoorlie-hospital-mental-health-unit-unfit-says-advocate
• NSW Health 2019, Wayfinding for Healthcare Facilities, NSW Health, Guideline, viewed 25 October 2019, http://www.healthshare.nsw.gov.au/__data/assets/pdf_file/0005/321998/Wayfinding_for_Healthcare_Facilities_-_Guideline.pdf
• Theodore, D 2016, ‘Better Design, Better Hospitals’, CMAJ, volume 188(12), viewed 25 October 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008943/
• Ulrich, R, Berry, L and Quan, X 2010, ‘A Conceptual Framework for the Domain of Evidence-Based Design’, Health Environments Research and Design Journal, volume 4(1), viewed 25 October 2019, https://journals.sagepub.com/doi/pdf/10.1177/193758671000400107

(Answers: b, f, d)