The first standard ever developed in Canada for the design and construction of new hospitals and other medical facilities could mark a major advance in the working conditions of doctors, nurses and support staff.
The standard, launched by CSA Standards, is based on the idea that better planning, design and construction can improve safety and care for both patients and hospital staff, and make hospitals more cost effective. The standard covers new hospitals, doctors’ and dentists’ offices and clinics.
“Ultimately, bad hospital design can kill,” said Bonnie Rose, president of CSA Standards.
At the document’s launch, Rose said the 400-page CSA Z8000 Health Care Facilities Standard creates a common national standard for hospital design. It provides planners with guidelines that go beyond building codes by setting out requirements specific to medical facilities.
The main purpose of the standard is to reduce the risk of hospital–acquired infection, plan for pandemics, and improve care of newborns, the elderly and obese patients. Every year, about 250,000 hospital patients in Canada, or five to 10 per cent of those admitted, contract infections, Rose said.
The CSA technical committee that developed the standard also looked at how good design can improve patients’ well-being in general, as well as the working conditions of medical and support staff.
“The HCF (health care facility) shall be planned, designed and constructed to provide a safe workplace for all staff and to enable and support the application of occupational health and safety (OH&S) principles and practices,” according to a statement from the committee.
The standard is also aimed at recognizing and controlling hazards that are biological, chemical, physical, nuclear, psychosocial (e.g., stress, violence) and ergonomic. It urges managers to protect staff and limit the risk of mishaps, including “slips and falls, injuries from hazardous materials, fire, musculoskeletal injuries due to patient handling/lifting, and workplace violence including aggressive behaviour by patients or others.”
Ergonomic requirements include several concerning workstation space. There should be enough space, the standard says, that desks can be flexible and allow workers to sit or stand, as well as to easily move around while maintaining a “neutral body posture” for manual work and handling patient care.
“Working heights, reaches and clearances in all work areas should accommodate the range of staff sizes and allow for work from a standing posture or a seated posture through adjustable work surfaces. Workstation designs should be independently reviewed by an ergonomist,” the standard said.
At critical areas, such as patient bedsides and washrooms and in emergency bays, facility design should also allow enough space that staff can maintain “optimal postures” and safely perform tasks. “Space should allow for movement of stretchers, wheelchairs, portable equipment, additional staff, etc.”
According to the standard facilities should be designed to reduce the need for staff to lift and carry materials and supplies — either by means of physical layout and by automated systems, such as horizontal and vertical lifts and motorized devices.
Among the issues the standard addresses is the layout and equipping of patient rooms. Lifting patients is a major cause of injury among health workers. The standard recommends that almost all hospital bedrooms be equipped with a rail in the ceiling for a mechanical patient-lifting device. As well, the facility should have the means to provide mechanic patient lifting in all clinical areas — e.g., physiotherapy, diagnostic imaging — in the building.
In areas where it isn’t necessary, or desirable, to have a lift in the ceiling, as in maternity and mental health areas, rooms should have a reserved storage area to accommodate a portable lifting apparatus.
In operating rooms, the standard says, medical equipment should be built into the ceiling rather than stand on the floor to prevent tripping. Other operating room standards cover proper lighting for clinical staff to see the patient, temperature and humidity control, adequate space for new technology and medical staff PPE, including yellow robe, clear eye protective mask, N95 (particulate respirator) mask and sterile gloves.
In emergency reception and other areas where medical workers are required to deal with the public, the facility should provide ventilation to reduce the chance of airborne infection and effective protection for staff against droplets.
Working in confined spaces can be a problem for support workers, and one requirement stipulates that equipment be designed so that workers are not compelled to crouch down and crawl under it.
For maintenance and engineering staff, the facility should provide a means to lift heavy tools and equipment to a roof or other high space. In dealing with equipment, they should be able to easily access maintenance points and “low ceiling crawl spaces should be avoided.”
Jeffrey Kraegel, CSA Standards project manager, says health-care workers provided many of the more than 1,000 comments the CSA received during the 60-day public review period. He described their response as “tremendous.”
“They saw this as an opportunity to shape what hospitals were doing. They had not had this before,” he said.
Many of these comments reflected common concerns, Kraegel said. Medical workers wanted their workplaces to require a minimum of lifting, reaching and repetitive movement. They also wanted to see more workstations and asked to have them made more comfortable.
The standard focused on five general areas, known by the acronym OASIS: operations (effective use of equipment, the environment of care); accessibility (patient access to care, wait-times, access to patient information); safety and security (eliminating medical errors); infection control (reducing risks of hospital-acquired infection); and sustainability (creating socially responsible buildings).
To contain infection, they recommend hospitals provide almost all patients with single rooms. Better ventilation, convenient hand-washing stations and easily cleaned walls and floors also reduce infection from spreading.
The standard also covers use of natural light and nature art works, which are thought to speed patient recovery.
CSA standards are developed by committees of volunteer experts which, in this case, included architects, facility managers and government officials. Before publication, a draft of the standard went for a 60-day public review. Rose said more than 1,000 comments were received, and all were reviewed and discussed.
The hospital environment must change because health-care itself has changed a lot in recent years, said Dr. Antoine Pronovost, medical director of the trauma and neurosurgical intensive care unit at St. Michael’s Hospital in Toronto, where the standard was launched. Doctors and nurses face many new challenges.
For one thing, he explained, patients now are sicker then ever before and usually have more than one illness. “The sheer knowledge needed to take care of patients is greater than that of any one person,” he said. “Health-care has become a team sport.”
The new standard will help hospitals to get design right from the start, Pronovost added, and ultimately save money. For example, single rooms reduce the spread of bacteria and so reduce the length of time patients are in hospitals. They also reduce the chance that the facility will have to undertake major retrofits later on.
“The cheapest solution in the short run is not always the cheapest solution in the long run,” he said. “It should be an environment designed for the purpose of saving lives.”
The standard, which drew on practices in many parts of the world, took four years to develop. It was a lengthy process, Rose said, because the standards had to be based on evidence, and they wanted to examine fully the pros and cons of each.
“It was important to get it right rather than get it fast,” she said.
The CSA is an independent, not-for-profit association that develops standards for government, business and consumers for a wide variety of products and services. While its standards are not mandatory, Rose said, she expects the new standard will be adopted by most facilities across the country.
“Seven provinces were at the table for this standard. They are aware that there is a gap,” she said. “We see this as the standard for future facilities. It’s the next generation. We believe it will drive best practices.”
British Columbia, Alberta, Manitoba, Ontario, Quebec, Newfoundland and Labrador and New Brunswick, as well as the federal Public Health Agency of Canada, participated in developing the standard. The project received funding from all provinces and territories, while CSA Standards provided the rest.
This is the first edition of the standard, which will be re-examined every five years. Rose said they welcome comments for the second edition.