Grabowski on Patient Experience

Posted on September 15, 2010


Bill Grabowski was a healthcare architect I was lucky enough to work with. He interviewed me for my position at a previous employer in Baltimore and was a fellow UVA graduate, so I had a certain bond with him. When he was hospitalized with complications surrounding his heart defect, I would visit him in Johns Hopkins Hospital as he waited for a lung and heart transplant.

During his months in the hospital, he was able to critically analyze his surrounds for some unique perspective on the patient experience. As I had noted in the piece on Keswick Jencks, the patient  perspective is invaluable to designers. Here are some of his thoughts:

Improving the physical design of healthcare treatment environments involves both “design influences” and “operations influences”. In essence there are four elements required to optimize an environment to allow healing:  adequate rest, health nutrition, physical exercise (physical well-being), and positive state of mind (mental well-being).

Adequate Rest:

  • Patient rooms should be shielded from noise generated at nurse stations.
  • Use of public address systems should be minimized. Technology exists to know where all personnel are at all times.
  • Just outside of my room a pair of double-egress doors spans the corridor. They are installed with electric hold-opens which release whenever the fire alarm system is activated. In such a large facility, something activates this system several times per week. The hold-opens must then be reset by maintenance personnel. Until that happens, all of the traffic in this busy corridor must go through these doors which slam shut very noisily. If quieter hardware is unavailable, placement of such doors should be more carefully considered.
  • There is a wall-mounted phone in the corridor outside my door. It is used by nurses, doctors and other hospital staff. Some of them speak rather loudly, and there is no acoustical shielding of their conversations. Besides the noise, I have overheard many conversations regarding other patients which were not meant for my ears.
  • There are many morning routines that could be better coordinated, therefore minimizing the number of disturbances of sleeping patients. When these are not coordinated the schedule can go like this:

–5.00 a.m.: Patient is awakened by lab technician to draw all bloodwork.
–6:00 a.m.: Patient awakened for a.m. vitals (P.P., temp, (on Sat.) weight.
–6:20 a.m.: Menus delivered for the following day’s meals.
–6:40 a.m.: Breakfast delivered

  • For relatively stable patients, there is no good reason to wake them just to take vitals, especially having them get out of bed to stand on a scale. Unless labwork is required for an a.m. procedure, or more frequent labs are required to monitor a quickly changing situation, there is again no reason to wake someone out of a good sleep just to draw their blood. Schedule labs for stable patients later in the morning. There also is no good reason for separate deliveries of menus and meals.
  • My particular patient room corridor was very busy with through traffic. Cath labs and O.R.s were south of my room, and the post-op I.C.U. was to the north. This situation obviously made my unit a throughway, which significantly contributed to the general noise levels. One particularly annoying disturbance was created by the tendency of staff members to carry on conversations the entire length of the corridor.

Healthy Nutrition:

  • The problem of delivering a fresh, hot, appetizing meal to every room of a 1000-bed hospital is a very difficult proposition.
  • Menu choices: This hospital seems to try very hard to put variety in the menu, with a different selection of entrees every day. Since most patients stay for less than a week though, this effort has no positive effect on maintaining their appetites. An opposite approach might be more effective. Offer the same menu every day, with a reasonably large selection. Patients will have more of a chance of finding something to their liking, and can opt to order the same selection for several days, knowing that it will be something they can stomach.
  • Cereal: Each day there are two or three cold cereal offerings. I see no reason why all cereals can not be made available every day.
  • Fresh vegetables: Fresh raw vegetables should be emphasized. Cooked vegetables are never going to be great when prepared on an institutional scale.
  • Bread: This is one area where spending more on the basic food will result in better meals for the patient. Any nutritionist will emphasize that bread made with white, over-enriched flour has very little if any nutritional value. Meanwhile, other grains and nuts are a good source of nutrition and help to bolster “good” cholesterol. The average hospital menu, however, is full of white bread selections and lacking in other grains and nuts.

Physical Exercise:

  • When a person enters the hospital, their physical activity has (in most cases) dropped from its normal level. Whether hospitalized for acute illness, infection, injury or an elective surgical procedure, returning to a normal level of physical activity is necessary for full recovery. Unfortunately, most hospitals do not provide much encouragement of physical activity.
  • Walking is generally the only form of exercise most patients get. Hospital corridors are not the best place to get in an energetic walk, however. Providing an area where patients can use some simple exercise equipment could help to speed their recovery and better prepare them for eventual discharge. A few light free weights, a treadmill and a stationary bike on each unit would be a big help. Often a patient doesn’t realize how weak they’ve become lying around in a hospital until they’re discharged.

My friend and colleague Bill Grabowski passed away in 2004 awaiting his transplants. He left me with stories and life lessons as well as healthcare design lessons—a legacy I can only hope to pass on in part here.  Thanks, Bill.