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#177 - 🏥 Designing Healing Spaces (ft. Dr. Nora Colman & Sarah Walter)





Hello Friends 👋

This week on the incubator, Dr. Nora Colman, a pediatric critical care physician, and Sarah Walter, a registered architect and senior medical planner, delve into the intricacies of designing Neonatal Intensive Care Units (NICUs). They explore the impact of the built environment on neonatal care, emphasizing evidence-based design and the need for healthcare architecture to support patient outcomes. Discussions revolve around how elements like lighting, noise, and spatial design influence both the health of newborns and the efficiency of care. The episode underscores the importance of collaboration between healthcare professionals and architects in creating optimal NICU environments, with real-world examples and innovative approaches highlighted.

Enjoy!

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Learn more about NICU Design Standards here: https://nicudesign.nd.edu/nicu-standards/



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Short Bio: Nora is an Assistant Professor in Pediatrics in the division of Pediatric Critical Care Medicine at Children’s Healthcare of Atlanta and the Fellowship Program Director. Her research focuses on the delivery of quality and patient safety-focused simulation. She has extensive experience in leading system wide initiatives where simulation has been used as vehicle to meet system wide quality goals. She is passionate about the role of simulation as a means to proactively identify latent safety threats in new healthcare design and has experience in the application of simulation in early facility design, prototype testing, clinical systems testing, device development, and education. Her strong clinical background coupled with simulation and patient safety experience allows her to impact patient care in multiple facets


Short Bio: As a registered architect and Senior Medical Planner with Page, Sarah has nationwide experience including strategic facility planning; campus transformation; and the programming, planning and design of healthcare facilities ranging in scale and complexity from 40,000 to 1.5 million square feet. Her dedication to the philosophy that design has the power to affect the physical, emotional and social well-being of the individual and the broader community has led her to focus her career on healthcare campuses and environments.  Sarah passionate about the art and humanity of healthcare design, she is a strategic and analytical thinker who is well-versed in the growing body of Evidence Based Design research.

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The transcript of today's episode can be found below 👇

Ben Courchia MD (00:00.9)

Hello everybody, welcome back to the incubator podcast. We are back with a new interview. Daphne, how are you this morning?

 

Daphna Yasova Barbeau, MD (she/her) (00:07.746)

I'm doing well. We've been looking forward to this interview. I think basically since dr. Coleman came to join us at Delphi our first Delphi

 

Ben Courchia MD (00:17.424)

That is correct. I think you were the one who suggested her as a speaker and we were all quite baffled by what you presented, Nora, it was fascinating to see this topic being addressed of architectural design of, I guess, medical facilities and to be quite general, but in this case, we were talking about ICU. So it's very exciting that we are actually getting to record this episode now and dive a little bit more into this topic.

 

Daphna Yasova Barbeau, MD (she/her) (00:22.222)

Mm-hmm.

 

Ben Courchia MD (00:46.376)

But we are joined by two guests today. There you go, Daphna, first strike. We should have a little fun of all the...

 

Daphna Yasova Barbeau, MD (she/her) (00:50.594)

Hmm.

 

Daphna Yasova Barbeau, MD (she/her) (00:56.154)

I know, we put a dollar in every time we have left our phone.

 

Ben Courchia MD (01:00.)

Yeah. But we're joined by Nora Coleman and Sarah Walters. Sarah, Nora, thank you for joining the show.

 

Nora Colman (01:07.989)

Thank you so much for having us, really excited to be here today.

 

Sarah Walter (01:12.18)

Yes, thank you.

 

Ben Courchia MD (01:14.236)

If not, can you tell us a little bit about our guest? Yeah, go for it.

 

Daphna Yasova Barbeau, MD (she/her) (01:14.93)

Yeah, shall I introduce them, please? So Dr. Nora Coleman is an assistant professor in pediatrics in the Division of Pediatric Critical Care Medicine at Children's Health Care Atlanta and is also the fellowship program director. Her research focuses on the delivery of quality and patient safety focused simulation. She has extensive experience in leading system-wide initiatives where simulation has been used as a vehicle to meet system-wide quality goals. She's passionate about the role of SIM. as a means to proactively identify latent safety threats in healthcare design and has experience in the application of simulation in early facility design, prototype testing, clinical systems testing, device development, and education. And we also welcome Sarah Walter, a registered architect and senior medical planner with PAGE. Sarah has nationwide experience, including strategic facility planning, campus transformation, and the programming, planning, and design of healthcare facilities ranging in scale and complexity from 40,000 to 1.5 million square feet. She has a philosophy that design has the power to affect the physical, emotional, and social well-being of the individual and the broader community. We are very happy to welcome you both. So I'll start, okay? Right, Ben? Okay. So, I mean, this is something that is near and dear to my…

 

Ben Courchia MD (02:31.355)

I'll allow it.

 

Daphna Yasova Barbeau, MD (she/her) (02:37.038)

personal and professional interests. But for people who are like, what's the big deal? Why even talk about unit design? Let's say, you know, we have mostly neonatologists and NICU professionals, but we can keep it even pretty broad. Why care about the way we design healthcare facilities?

 

Nora Colman (02:59.125)

Well, I guess I'll start. So I never really thought about the environment that I work in, honestly, until we started building our new hospital at Children's Healthcare of Atlanta. And that's where I got to meet Sarah. And I started to understand how much the built environment actually impacts what I do on an everyday basis. And so then I started to dig deep into elements of the built environment and how that really has an effect on how I deliver care, And then I realized there's actually research in that. And that's something that comes out of the architecture industry. So I'm super excited to be here today because I think there's a great opportunity to bridge this gap between what the architects know about design and evidence-based design and what the clinicians know about care delivery. And by working together, we have the opportunity to really shape how we design hospitals so that they're the safest and most efficient that they can be.

 

Daphna Yasova Barbeau, MD (she/her) (03:57.034)

Yeah, it sounds like, you know, healthcare professionals really have this expertise in knowing like what they need, right? But we lack how to get there sometimes. And in general, a lot of times healthcare facilities are designed without healthcare professional involvement. Is that right?

 

Nora Colman (04:18.717)

Yes, it's hard to get effective clinician input because you sit around a table, and I think Sarah can speak to this too, you sit around a table, you can only fit so many people around the table. Often those people at the table are going to be managers and upper level people that aren't actually delivering care. So how they imagine things happening at the frontline of care delivery is actually not how things are happening. They don't know the workarounds that staff are creating. They don't know.

 

Daphna Yasova Barbeau, MD (she/her) (04:29.558)

Hmm.

 

Nora Colman (04:45.437)

like the nuances of what the staff is really challenged with. And they make a lot of assumptions and then bring those final decisions to the design table. Then your clinicians come into the space, and they're like, wait a minute, this doesn't work for us. So I think Sarah can speak even more to end user engagement in the design process.

 

Sarah Walter (05:04.883)

Yeah, it really is critical and it really is becoming, or not even becoming, but it really is a sort of standard to the design process at this point. Hospitals and healthcare environments are so complex and they're ever evolving, so there's always new technology and there's always new research and operational care models that are being developed to optimize your work and how you do your work and the outcomes that work yields. So for us to engage with clinicians, and as Dr. Coleman mentioned, it really is key to engage a spectrum of perspectives along the way. So we need to engage with the frontline staff and nurses and the techs who are doing all the nitty gritty day to day. We need to engage with providers and leadership, but we can't stop there. We also need to talk to materials management and your EVS staff? How are we restocking this unit? And how do we design a space when we have the opportunity to do a thorough renovation or a new construction? How do we design a space that really supports every aspect of your work so that you can do your work easier and better?

 

Daphna Yasova Barbeau, MD (she/her) (06:03.042)

Mm.

 

Daphna Yasova Barbeau, MD (she/her) (06:23.458)

Mm-hmm. So, you know, we had this experience, I feel like we moved into a new hospital just two years ago now, I guess, Ben. Time is flying. And I think one of the most like salient things is they had designed a bed space where at every single bed space, there was a workspace for a staff member, presumably a nurse. And within days of moving into the unit, all the nurses had pulled up. chairs and their computers on wheels. So they had invested, I can't even imagine what was invested in the building of these workspaces with computers that have literally still not, they're still not used two years later. And that's just, you know, a wasteful aspect. But I'm really interested to talk about some of these...

 

concepts, let's say, that I'm still learning about, about how the built environment effects are really the delivery of care, like you were talking about.

 

Nora Colman (01:05.571)

So just to take a little bit of a step back, because I think, you know, before I started doing this work, I actually learned a lot about my practice and just doing simulation to test our new hospital. I was like, oh my God, where do I put my gloves, you know, when I'm prepping for a sterile procedure, like on the trash can, right? So like you said, like we imagine like, oh my God, a doctor preps all of their sterile material on a sterile tray before doing a procedure. And here I am putting my gloves on the top of the trash.

 

And so there's this concept of like, work is imagined versus work is done. Like you just said, like they imagine this nursing station in your new NICU and it would work perfectly. And then you actually get into the space and the staff are not utilizing that space at all like it was intended to. So the reason kind of behind doing all of this work is because healthcare is so complex, right? All of the work system elements like your environment, your physical space, your people, your tasks, your tools, your equipment,

 

complex and dynamic way. And so it's super important to kind of tease apart those complex interactions so that we can think about how we can design that space in a safe and efficient way. And there's a body of research in the architecture industry that's called evidence-based design. And this really describes built environment features that we know impact healthcare outcomes. And Sarah is more of an expert in this area than I am, but things in particular that relate to the NICU are like...

 

temperature, noise control, lighting, privacy, things that minimize cross-contamination and infection, dirty versus clean workflow. And so we're excited to kind of get into some of these things and talk about this body of evidence that I never even knew existed, but is what all of the architects kind of based their work around.

 

Daphna Yasova Barbeau, MD (she/her) (02:41.55)

Thank you.

 

Daphna Yasova Barbeau, MD (she/her) (02:57.742)

That's awesome.

 

Nora Colman (02:59.754)

Sarah, do you want to add more? Do you have more to add about evidence-based design?

 

Sarah Walter (03:04.207)

Sure, so it's definitely a growing and evolving kind of field within architecture and within not just architecture but also interior design and just design in general. So if we think about you know architecture, the discipline of architecture is really a blend of art and science and you know historically that science has always been around building technology like how do you

 

detail, the brick going together and how do you structure it. So it's that, but lately, you know, and this has started really, I say lately, but since the seventies, I suppose, there's been a growing interest in developing more rigorous and scientifically based research around how does the environment affect behavior and mood

 

effectively clinical outcomes. And exactly as Nora mentioned, especially in the NICU, we're really paying a lot of attention to lighting. And once you dig into the science of lighting, it can really start to blow your mind, but you have to think about how do we layer the lighting in a NICU room, for example, so that we have task lighting, but ambient lighting, dimmable lighting. So,

 

Daphna Yasova Barbeau, MD (she/her) (04:18.254)

Mm-hmm.

 

Sarah Walter (04:30.539)

what color is the light, what temperature is the light. So there's a lot of science to be had around this specific design and performance attributes of spaces. And that becomes particularly critical when we're dealing with a neonate who's so responsive to the environment and needing that environment a certain way to support further development.

 

Ben Courchia MD (05:00.519)

I think to me what's interesting is that we're talking about very important aspects of the environment in which we are providing care. But I'm sure there's a lot of people listening saying, well, my unit is not that bad. We kind of have a nice little setup. And I think that for people, they say, you know what? The lighting maybe it's not that important because we put these little covers over the baby's isolates so they're in the dark anyway. But I'm just curious if you guys have a lot of experience.

 

talking about the NICUs specifically, what are some of the things that you think are probably very commonly seen around NICUs throughout the country, maybe around the world, that clearly are not functional, could be very much improved, that directly affect patient outcomes? In your body of work, what are some of the things like that you've identified?

 

Sarah Walter (05:52.443)

I think I'll go first with this one. A lack of space is a big one. So units that were designed 20 years ago, we have a lot of equipment now, a lot more staff that need to access the baby when an emergency or even in day-to-day care. So a lack of space, I think, might be one of the biggest issues. The environmental controls, you can work around them, like you're saying, putting covers over the isolate.

 

But when you don't have enough space and everyone is jumbled and crammed to get in to access what they need to at the baby, what happens to the parents in that situation? Do we have enough space to accommodate the parent or the caregiver staying with the baby? There's a lot of literature to support encouraging the parents and the family and the caregivers to stay involved in the care. So I think that space is a big one that we see as

 

probably the biggest pressure point in a lot of NICU environments.

 

Nora Colman (07:00.902)

Yeah, to add to that, I think about the complexity of care delivery, right? Not a NICU physician, but I'm a PICU physician. And so the amount of technology and what we are doing these days to support critically ill infants is only expanding, right? So now we have ECMO and the oscillator and bedside surgery, and you guys do cooling for HIE and things like that. So

 

Those patients are extremely sick and they require a lot of support and those care episodes are highly complex. And I think what I think about is, does my environment actually support my ability to do these complex care episodes or is my environment in the way? Like how many times have you been like, oh my God, this wall, like I can't fit between the bed, I don't have enough space from all of my ventilators, my nurse is like cranking their neck, as they're trying to hook.

 

things up to the IV in between the monitor, right? And so you want your environment to not add to the, these episodes, these kids are already super complex. It takes a whole squad, a whole team to manage some of these peri-arrest or cardiac arrest episodes, right? And so what I think about is, is my environment actually contributing to how hard it already is to take care of this patient? And sometimes it is.

 

And so like Tessera was saying, we think about space and does your open bay actually accommodate all the equipment and technology you need to actually deliver care in these highest complexity episodes? And often the times is no, like how many times does your equipment spill out into the hallway? Or are you coding a baby in an open bay and like there's a mom next door or there's a baby next door, right? And so those are the things that I think about.

 

where there's opportunity for NICUs for all of us to grow and develop our design so that it makes our life easier and not harder. And moving from open bays to private rooms, I think are one of the biggest challenges for NICU. There's a lot of data about the benefit of private rooms as compared to open bays, but as a clinician,

 

Nora Colman (09:08.266)

We have a really hard time making that transition, right? Because we're like, I can't see anything. I can't see my baby. I can't see my monitor. Like, what am I gonna do if the kid is coding and nobody notices, right? Like those are the realities of care that are super challenging to then change your operational model to fit a new design or to have a new design and then, you know, redo your operations and how you think about caring for your patients and your, you know, as a unit.

 

Ben Courchia MD (09:18.112)

Right.

 

Ben Courchia MD (09:34.423)

I think for every neonatologist, if you've been involved, like you said, either in a code or just simply like taking the patient down to MRI, right? The kid on the vent where it's like, all right, like the bag is behind the isolate. Let me just like get the EMBU bag. Then who's like the plug to unplug the isolate is unreachable. Like you have to find the tiniest, uh, healthcare worker, whether it is a nurse, like you have to find the most petite person like, Hey, can you like get behind there and unplugged?

 

Daphna Yasova Barbeau, MD (she/her) (09:45.506)

Mm-hmm.

 

Daphna Yasova Barbeau, MD (she/her) (09:52.592)

I'm sorry.

 

Daphna Yasova Barbeau, MD (she/her) (10:00.145)

Sometimes it's the parent, right? Like can you, can you unplug the bed for us?

 

Ben Courchia MD (10:04.359)

And what's funny to me is that as I've worked in the past with the BPD program, and we did a lot of collaboration with the PICU, after babies were transferred to the PICU, after they reached a certain level of age, then you walk into the PICU and you see your baby suddenly in this big PICU room and you're like, this is kind of nice. You know, you walk around the bed and I think it's that kind of thing where we don't even realize what a patient's bed space could look like.

 

Daphna Yasova Barbeau, MD (she/her) (10:23.176)

Mm-hmm.

 

Ben Courchia MD (10:34.519)

And to me, it really dawned on me not until I went to the PICU and saw my same patient that was in the NICU a few weeks before now suddenly in a PICU bed with a much larger room designed for a pediatric patient granted. Um, but it felt like there was, it was much safer as well. I was not going to stumble upon a cable, uh, an IV tubing and so on and so forth. So.

 

Daphna Yasova Barbeau, MD (she/her) (10:55.806)

Yeah. The patient is smaller, but the equipment is not smaller. Right.

 

Ben Courchia MD (10:59.071)

No, right. It's exactly right. And so I guess there are many questions that are coming up. I think if you're listening to this, you may say, well, you know, my hospital is not looking to redesign anytime soon. So we're not building a new facility. We're not building a new wing. And so we're stuck with whatever we have. And I know from doing research for this episode that, yes, if your hospital is being in the midst of a whole redesign, there's a lot of opportunities to improve. And then we can talk about that.

 

Sarah Walter (10:59.355)

It's very true.

 

Nora Colman (10:59.41)

Right? Yeah.

 

Ben Courchia MD (11:28.859)

But there are also ways to optimize your workspace, even if you have the constraint of your current architecture. Can you tell us a little bit how do we take this challenge on, knowing that no new building is going to be a... Yeah, go ahead.

 

Daphna Yasova Barbeau, MD (she/her) (11:43.182)

Can I ask a question before they answer that question? Well, I think Nora mentioned something during her talk that has really stuck with me about how our environment drives our behavior. And so we have certain behaviors or workflows, and health care professionals are so adaptable that we've just changed the way we do things because that's how the environment was built.

 

Ben Courchia MD (11:46.689)

I'll get like a one.

 

Daphna Yasova Barbeau, MD (she/her) (12:11.67)

So I was actually hoping you could address some of those examples, and then we can talk about how to fix them.

 

Nora Colman (12:20.178)

Yeah, absolutely. This is the stuff that I love, right? So you're exactly right. Like space utilization directly drives human behavior. People are gonna do whatever is, take the path of least resistance, right? And those are what we call workarounds. And we all do them in our everyday life, like me putting my gloves on the trash, right? Complete workaround because there's not enough space around the bedside for me to prep my sterile equipment, right? So those workarounds are always drift from best practice. Like maybe you're,

 

in terms of a process, right? Like maybe your nurses are time-pressured when you're about to intubate or code a baby and they don't do an independent double-check, right? Because they're like, I just need to drop epinephrine really quickly. And then by accident, it's the wrong dose, right? And so those workarounds are drift from best practice. And that is where your margin for error occurs. So we have to think about fixing our system to prevent workarounds from happening, right? If we keep targeting...

 

teaching people to do the right thing, it's often not sustainable. Certainly not these days where like your nursing staff is constantly turning over, right? So if we think about our current system, maybe we're not designing a new environment, but we have a working system and people have created a lot of work grounds over the years. So we have to take a step back and really think about.

 

What are elements within the work system that we can fix, including the environment? And there are small changes you can make in your environment that are not cost prohibitive to really drive people to do the right thing, right? So I think about standardizing intubation, right? We did some work in our emergency department. Nothing was standardized in terms of what equipment was being pulled for intubation. So we created a...

 

RT Braslow cart, right? And so they would just open the tray, open the drawer and the trays were standardized. Boom, you just drove care delivery and you just standardized care delivery and shaped human behavior by doing something in your environment without doing training. And so those are the kinds of things that really start to be resilient and sustainable as work system changes in your environment. So did that answer your question, Daphna?

 

Daphna Yasova Barbeau, MD (she/her) (14:30.274)

Yeah, I want more examples like that.

 

Nora Colman (14:33.55)

Um, so, um, there's, there can be systems, culture process and built environment work. Um, like maybe you don't have good communication during codes, right? So is that because of where your team members are standing? So maybe it's an ergonomic problem. Maybe you've got a documentation station at your alcove, but no ability to have something that's mobile so that your team lead and your

 

documenter can actually stand next to each other. So maybe you actually need a cow in that space, or maybe you need to remove a fixed element from your environment so that you have the mobility to optimize your ergonomics. That's something that will drive human behavior. Some other examples are like, where's your med zone? Where in the actual space of your ICU and your NICU are your...

 

your nurses drawing meds. If they're drawing it in a very loud, distracted area, like if your pixis is in the middle of your unit behind the nursing work desk, like they're probably not doing an independent double check, right? Because they're getting interrupted a gajillion times. So where are you? How does your environment shape where your nurses are actually pulling medications out and, and drawing those medications? Those all like play into patient safety things.

 

where are your monitors located so that you actually have sight lines and visibility lines. If your patient is coding and you're standing at the head of the bed and your monitor is like literally behind you, we're attuned to like listen to a pulse ox, but like maybe your patient's going into an arrhythmia and now you've missed it because you're at the head of the bed in your monitor and you can't see your monitor. So those are other things like in your environment. If we change where your monitor is located or we have a dual monitor,

 

then you could potentially see some of those subtle changes in your patient that you would otherwise be missed. But those are not human factors. Those are environmental factors that shape my decision making. And so those are things in your built environment that we start to think about. Do you guys relate? Yeah. There are so many things, right? There are so many things that really shape what we do in the space that we work that we don't even think about.

 

Daphna Yasova Barbeau, MD (she/her) (16:40.097)

Yeah, absolutely, absolutely.

 

Daphna Yasova Barbeau, MD (she/her) (16:49.262)

Yeah, I feel like some things are top of mind, like things, and we didn't even get into the neurodevelopmental design things about the NICU. We'll get to that. That's a whole nother thing. But things about our unit that I know that interfere with our everyday. But maybe there's some things that we don't even notice are interfering with our everyday workflow. Like...

 

What is the process for a team to say, like, let's find some of those factors? You know, I think because we are, like you said, we just make do with what we have. Sometimes we'd end up that process has been going on in some units for decades. How do we find those pressure points, I think you call them, and then so we can make changes?

 

Nora Colman (17:41.318)

Yeah, so that's a great question. So we have published something called Translational Work Integrating Simulation and Systems Testing. And so using simulation as a risk mitigation strategy to actually uncover all of these nuances and latent conditions in your work environment and then identifying opportunities for improvement and embedding those improvements into training. So the way to really, you have to change your way of thinking about how you look at your work system. So I think the first...

 

The first part is understanding that your environment that has a big role in what you do and has a big role on your patient safety and your workflow efficiency and can contribute to work around. So if you start to look at your work through a lens that focuses on the system, you start to see problems in your system, whether they're process problems, operational problems, environment problems. And then we use simulation as a tool to like really...

 

represent these highly complex scenarios and then tease apart all of these latent conditions in your environment. So an easy one, like when you run a code, are your drugs all over the bed?

 

Daphna Yasova Barbeau, MD (she/her) (18:50.272)

What do you mean? Like we pull them and...

 

Nora Colman (18:51.066)

Like as the syringes like just laying out in front of on the babies like when we run code

 

Ben Courchia MD (18:55.349)

Usually on the cart on the usually it's on the top of the cart.

 

Daphna Yasova Barbeau, MD (she/her) (18:57.614)

cart. Yeah, the top of the crush.

 

Nora Colman (18:59.782)

So ours end up on the bed and it's like chaos, right? We have like syringes with drugs, syringes that are empty, garbage, like flushes, right? And so I'm like, does this, I asked the nurses in sim, I'm like, doesn't this stress you out? Like, this is chaos to me. Like, I don't, how do you know what syringe, what syringe has what drug and if it's empty or not, like it's just a mess on the bed, right? And they were like, yeah, it is kind of annoying that like there's trash and.

 

filled syringes and empty syringes. And so we took like a utensil tray and now our meds are organized, right? So like one tray has like all the prepped meds, one tray has the flushes, one tray has the trash, right? So like, those are some of the things that are super simple to solve in your environment that we found out during simulation and it was a super easy fix. Like, you know, we just bought them off Amazon, right? Yeah.

 

Daphna Yasova Barbeau, MD (she/her) (19:50.646)

Yeah, that's like a dollar store solution. Yeah. Okay. That's very cool.

 

Ben Courchia MD (19:58.799)

You completely hijacked my question line by the way.

 

Daphna Yasova Barbeau, MD (she/her) (20:00.154)

So... Oh, I did? Why? No, you go.

 

Sarah Walter (20:01.815)

Hahaha

 

Nora Colman (20:02.548)

Hahaha

 

Ben Courchia MD (20:02.919)

That's alright though, keep going.

 

No no you finish your line or I'll get back.

 

Daphna Yasova Barbeau, MD (she/her) (20:08.362)

No, I want to learn more about the sims. Like, you know, again, if these are kind of latent conditions, so like, what are the sims we should be running to check our spaces?

 

Nora Colman (20:20.966)

Yeah. So in a working environment, you want to do either routine is fine, highly complex scenarios, like your sickest type of patient you would ever see. Or things that are really rare, like if you open the belly at the bedside for a kid with neck, or if you cool, but you don't do it frequently, or ECMO or something like that, would maybe be your unique situations or your very high risk, might just be a cardiac arrest episode, or your routine stuff just might be a patient admission, or

 

a patient getting transferred from the delivery room, something that would fit into your, you know, how your unit functions. And then you actually use a specific debriefing strategy that looks at the system. So you ask, as you debrief your teams, you actually ask very specific questions about how the environment, the system, the process actually contribute to latent conditions. And then you get your team to say like, okay,

 

if I don't do an independent double check because it's too noisy in the med zone, what's the risk to my patient? And then you really start to uncover those latent conditions and tease out what the impact of those latent conditions are. And then your stakeholder team, your educators, your unit directors can help identify opportunities for improvement. And so it's really about using a special deep.

 

briefing approach to kind of tease out all those latent conditions as it relates to your work system. So you're not asking, did you learn how to do an independent double check? You're asking what is the elements in your built environment that make you not do that independent double check? Is it interruptions? Is it distractions? Is it where the location of your med zone actually is? Those kinds of things. And so you're starting to ask very different questions in your debrief that aren't...

 

looking at knowledge gaps of individuals but system gaps instead.

 

Daphna Yasova Barbeau, MD (she/her) (22:14.246)

Ben, now I'm letting you ask your questions. Yeah.

 

Ben Courchia MD (22:14.379)

Okay, now I can go. Right. No, I guess my question to you is then, how do people, if let's say now there's redesign, I think one of the issues, I have actually been in one of the rooms as a fellow of all things. I don't know what I was doing in that discussion, but about like redesigning a space. But what I remember is that there are so many rules and regulations about like,

 

how certain things have to be certain sizes. And you can clearly tell that these rules are definitely just coming top down for adult stuff. Like, I don't know, like the hallways have to be a certain size. So like, like a stretcher could be pushed through, which great. But like, do like, that's not really something that applies too much in the NICU because our, we don't really use stretchers. We use the isolate. So what I'm saying is that how do you navigate these competing forces?

 

in order to actually come to a consensus where you have an integrated space that is good for us, neonatologist and pediatricians in general, but also fulfills all the coding and zoning stuff that have to be taken care of.

 

Sarah Walter (23:28.303)

Well, that's really the fun part. You know, there are, in healthcare, there are a lot, for us anyway. That's the thrill.

 

Ben Courchia MD (23:33.199)

Fun, fun. I was not going to, I was not expecting fun to be, uh, this sounds awful.

 

Nora Colman (23:36.886)

I'm sorry.

 

Daphna Yasova Barbeau, MD (she/her) (23:39.12)

Yeah, that doesn't sound fun.

 

Sarah Walter (23:43.259)

So for us, that is the fun part. We, you know, if you can design a hospital, then I think you can design anything. I mean, people are gonna smack me for saying that, but it's very complex, you know? And if you can balance all of these code requirements, all of these guidelines that sometimes become more than just guidelines, sometimes they're actually enforceable as kind of code. And

 

all of the best practices, keeping in mind workflows and optimization of where a person on the unit wants to be when they're doing this task and how high are they reaching, how low are they bending. And then, you know, looking at it from all the different perspectives, what is the family member seeing? What is the patient experiencing? It's tremendously complex. And I think that, you know, to be honest,

 

the evidence-based design literature that's coming out. In some ways it complicates that, but in terms of it's adding another parameter, but it also helps to simplify some of those difficult decisions. So we can look to literature to help support a decision that we're making around, do we stick with open bays or do we go to single family or private patient rooms? What kind of lighting do we want to accommodate? Do we want...

 

a mom and dad to be accommodated within the room? Are we going to provide special spaces for couplet care? So, if we have a mother who is also an inpatient recovering from delivery and a neonate, if the science says that these two patients need to be together to support each other's recovery, how can we design a space that actually does that?

 

I think those are the things that are really exciting, but challenging in a good way.

 

Ben Courchia MD (25:48.775)

I'm so sorry. I have actually a new workspace. So I'm learning how to use my new workspace. I think the other question that I had about this was that obviously this has to be very intentional. There's a deliberate will to make sure that things are connected and work together well, which I think that in the design and building phases can sometime be time consuming and sometimes resource consuming.

 

Daphna Yasova Barbeau, MD (she/her) (25:52.95)

See, you're learning your new workspace.

 

Ben Courchia MD (26:16.567)

knowing that institutions and hospitals in general want to do this fast and cheap as that's really the goal and make sure, I guess, that it does not necessarily need to be the best, but at least not the most awful, basically. That's the feeling that I've had from these past experiences. What has been the path to impress on our colleagues in administration and in construction that this is...

 

valuable time and that this is not insignificant work. How do we make sure everybody's on the same page?

 

Sarah Walter (26:56.263)

I think that Nora might have a great answer for this, but I do want to say too, in terms of balancing all of the code and best practices and desirable things that we want to include and plan for in designing a new environment or a renovated environment, integrating simulation into that process is tremendously valuable. So it's sort of proving by example in a way. So, you know,

 

at least the process that we went through and that we typically do. There's a lot of time spent where the architects and the design team will develop a concept, develop a preliminary set of options, design options for the clinical teams and the leadership group who's invested in making that space, you know, for them to review and make decisions on. And a lot of times that's 2D drawings. It might be 3D images. It could be a physical model that's

 

of a certain scale so it's, you know, you can sense the relationship of spaces. And we do full-size mock-ups, but what's becoming more popular, and kudos to Dr. Coleman and her team, and to everyone who's taking this on, is instead of just mocking up a space, and mocking it up means you could build it full-scale so that you can actually walk into that room, or the department even.

 

It might be made of cardboard, it might be made of actual building, you know, constructed walls, but you, instead of just looking around the space and saying, yep, this looks good, getting into the rigor of saying, okay, this looks good, now let's test it, let's really kick the tires, let's run one of these complex scenarios. And at least with Dr. Coleman, it was very scripted in that it wasn't about you making clinical decisions. It was about follow this,

 

kind of script, this is what we're doing, it's not a question of whether you should do this or shouldn't do that, like just follow these steps, retrieve this item and apply it to the patient, go do this, something went wrong, you've gotta run there. When you go through that actual case, that's where you start to see, oh, I can't reach the code blue button because it's behind this person when they're standing there to intubate or, oh,

 

Sarah Walter (29:20.911)

the computer is blocking my access to the oxygen, or whatever it might be. I think that's where you can really start to refine the design. So in a positive way and in a meaningful way. And you also start to build consensus. So sometimes what happens is the design is developed in a box and then the clinical teams come in and they don't understand why is there this table outside or this charting alcove outside of each patient room? Like,

 

What is that for? I don't know what that's for. But, you know, if you're engaged fully in the design process, then your team understands and has a say in an ownership and how that space is designed because it will support how they want to operate. So I think that's really the power of what Dr. Coleman does.

 

Daphna Yasova Barbeau, MD (she/her) (29:52.459)

Ha ha.

 

Ben Courchia MD (30:09.629)

And so Nora, maybe you can talk to us a little bit about this again, because I know you presented this at Delphi this year, but basically if you could tell the audience exactly what you worked on, which is quite mind blowing to have like, you had like a hanger basically, and you designed a fake hospital with like, it's not plywood, but it's just like temporary walls. And basically it was supposed to mimic

 

the new hospital and you ran simulation in that temporary space. Can you tell us a little bit about that story? How, how you were able to get to that because that's also not an insignificant place to reach. And then what, what have you learned? And then also what was the reaction from the rest of the team to seeing how sometimes it's not really perfect.

 

Nora Colman (30:56.07)

Yeah, no, I love talking about this stuff. And like I said, Sarah was part of this project and she was in there doing Sims and sometimes doing CPR in the middle of Sims. So it was a really, it was such an awesome opportunity for the frontline staff to really engage with the architects and feel heard. So we just built, we're moving in under a year. We built a 440 something bed children's hospital. It's 1.5 million square feet. It's massive.

 

and it's a complete replacement hospital for us. So in the early phases of design development, we actually had a hundred thousand square foot warehouse that we rented for a year and we did a cardboard city. So we built 15 clinical areas, operative areas, the bed tower and all the adjacencies. So like, where is all your support structures within that space, like your medication room.

 

clean supply, utility closets, care stations. And we built that all in cardboard. We looked at the overall layout of the unit in one phase of testing, and then we actually went into each of the rooms and then really dug deep into the design elements in the rooms itself. So an ICU room, a general care room, an operating room, the trauma bay, to really look at like all of the details, all of your fixed elements, like where's your code blue button? Where are your medical gases?

 

what height are they at, where are your monitors, your nurse server, the whole shebang. So we spent, we ran about 81 scenarios that represented routine events like, okay, let's just admit your patient all the way to the highest risk, like, okay, we're doing ECMO, we need to open the belly, we're doing bedside surgery to your high risk cases in the OR and the emergency departments as well.

 

And we brought in like over almost a thousand staff to run through these simulations. And so these are people that are actually working frontline. So you're getting that spectrum of experience and you're getting your frontline staff. We identified over 700 latent conditions that were related to the architectural design. And we estimated that we avoided $90 million in cost. So if we got into those, into the space.

 

Nora Colman (33:07.742)

That's how much it would have cost to change the design features to mitigate those latent conditions after construction. Now, go ahead. Sorry, Ben.

 

Ben Courchia MD (33:14.199)

But let me ask you a question because finding a space, building a temporary floor hospital, that takes time and that takes planning. So can you take us back to when does that idea sort of germinate in terms of when do you guys say, you know what, this is something that we need to do? And then the cost associated with this, is this then something where you're being told,

 

Ben Courchia MD (33:42.731)

Or is this the hospital that right away sees the values and says, yeah, we're going to do this before we break ground and make sure that we're doing this well.

 

Nora Colman (33:52.102)

Yeah, so it's a great question and one that we get frequently. So the earlier you engage your executive team and your architect team and get buy-in and to do this work, the better, because you want to make design changes as early on as possible. Once you pour concrete, your facilities team is not making design changes. I can promise you that it's way too expensive. Right. And so you want to fit this into the timeline. And Sarah can speak to like where simulation fits into the design planning, because everybody wants to stay on track and on budget.

 

to derail your, when your documents get filed for construction to begin, right? So the biggest thing is how do you convince executive teams to actually do this? For us, it was convincing them that return on investment was worth it, that we were actually, we had it, we were building a freestanding children's hospital from the ground up. Like this was our chance to do it right. This hospital is gonna be here for a very long time. Like let's put the time and energy into making this building as

 

safe and efficient as possible and that we had a unique opportunity to do that. That doesn't always, you know, people say, well, we'll just do what the lab, what they say to the architect firm, just do what you did last time, right? The reality is that we all do things differently, right? Like the way you and I deliver care is different because it's really influenced by our local micro work system, our culture and our unit based practice. So when you cut and paste

 

It's not gonna work, right? And your clinicians are gonna generate workarounds. So whether the facilities and your executive team wanna believe it or not, that is the reality. The other thing is that, if you're trying to do this early, talking to your executive team about return on investment in the long run. And what I've learned is that it's operating the building over time that is where all of the money goes into, right? Not just the initial construction.

 

So if you do this work early, you're going to understand about how process needs to change, how your operational infrastructure needs to change. You're going to inform staffing models. And you're going to be able to predict the long-term needs of your institution seven years in advance, much more like instead of getting into the building and then realizing you need 1,000 more FTEs to actually take care of your patients. And so some of those are going to be huge return on investments. The other thing is identifying.

 

Daphna Yasova Barbeau, MD (she/her) (36:09.11)

Hmm. Mm-hmm.

 

Nora Colman (36:15.978)

we identified so many latent conditions that were happening in our current practices, right? Like things around medication safety, surgical site infections, infection control and prevention, right? And so you really start to inform safety early on and you can actually fix things in your current practice as you start to design for your new hospital. And so we had a lot of quality and safety and accreditation being like, oh yeah, we just got dinged from by joint commission because we didn't do X, Y and Z, right? So we were able to...

 

Ben Courchia MD (36:42.332)

Mm-hmm.

 

Nora Colman (36:44.842)

Think about our current space as well as our future space. The other thing is if things, hospital designations are important to your system, like things like Magnet love this work, right? Like Joint Commission, Magnet, US News World Report, they wanna see that your hospital is doing things preemptively to mitigate risk. Magnet loves this stuff, I promise you. It engages end users, it focuses on safety, it's multidisciplinary, and so those are some of the...

 

non-tangible return on investment and your buy-in from your staff. People are stressed out in healthcare, right? Working in systems that do not function for them. And so by engaging them in this process, your staff is like, oh my God, somebody's listening to me. They actually want to know what I think and they're actually going to make changes to make my life better. And all of a sudden you've created a system culture that really invests and values frontline staff input. And that is a game changer.

 

for institutions that are really struggling to retain staff. So that's a little bit about how to try to convince your executive team to do this work. So our project was $2 million investment, but this was a $1.5 billion project. So it was a 0.01% investment in the terms of the big.

 

Daphna Yasova Barbeau, MD (she/her) (38:03.182)

Mm-hmm.

 

Nora Colman (38:06.106)

overall construction budget. So, and simulation can be scaled. So you might, you don't need a warehouse. I think Sarah can probably attest to really innovative areas to build mockups. Like, like Paige has built mockups in parking garages, right? Um, we had, we just did some simulation work for a NICU design and their shelved space was open. And so we built the mockup in their shelved space. It didn't cost them anything. Um.

 

Daphna Yasova Barbeau, MD (she/her) (38:19.598)

Mm-hmm.

 

Sarah Walter (38:20.004)

Mm-hmm.

 

Daphna Yasova Barbeau, MD (she/her) (38:27.875)

Hmm.

 

Mm-hmm.

 

Nora Colman (38:31.474)

And so you can really scale this work. You don't have to do it over a year. You don't have to do it in a warehouse. You can scale it to really meet your needs and fit your budget and timeline.

 

Daphna Yasova Barbeau, MD (she/her) (38:41.866)

Yeah, it seems like the cost of a medical error is astronomical. I mean, it seems obvious that that's something that is likely avoided through doing the work that you guys are doing. And you told us about the cost of fixing latent conditions. And you told us the overall budget for your sim was about $2 million. Is there some sort of calculation?

 

about all of the money saved versus what it costs to run.

 

Nora Colman (39:17.334)

We don't have, so that's the holy grail in like doing this type of work, right? So come back to me in like two years when we've actually moved into the building. But so the question, like as you said, is like the holy grail in simulation is can you impact patient outcomes, right? And can you actually mitigate risk? And so the question that we're always seeking to answer is if I make this X change in the environment, like did I actually reduce harm? And how much did that save me in like

 

Daphna Yasova Barbeau, MD (she/her) (39:23.886)

Mm-hmm.

 

Nora Colman (39:46.95)

like the cost that it was to pay for a patient fall or a medical error or a hospital acquired condition. So there's still a lot for those that are interested in research opportunities, like that is the holy grail that is yet to be filled is making that leap from like we made this change to we reduce medication errors by X number or we reduce patient falls or, you know, clabsies, right? Like those things are huge. As we talk about NICU environments,

 

Open bay to private rooms has been shown to reduce serious bacterial infections, right, because of infection control. So now linking all of that pre-design work to the overall outcome and the cost, that's where the next step in research is going.

 

Daphna Yasova Barbeau, MD (she/her) (40:33.395)

And that, your patient outcomes brings me to my next question. We talked a little bit about lighting in the NICU, but obviously the NICU environment, you know, we've got some decades of research now about how the environment impacts neurodevelopment in infants. So I hope you guys can spend some time talking about some of that research.

 

Nora Colman (40:55.402)

Sarah, do you want to start or?

 

Sarah Walter (40:56.955)

Sure. So when we, as designers, when we learn that some particular thing has an impact on a baby's development or some kind of clinical outcome, we start to dig into that thing. So for example, all of the literature suggests that breastfeeding is critically important.

 

for development. So how do we design spaces that support breastfeeding or breast milk expression for mothers? So we start to look at things like privacy. Can she do that in a private environment? And if it's an open bay, is there a space that she can go to? But every single extra step that we add in to achieving privacy starts to degrade

 

the efficacy of that measure. So if you have to schedule a room and get up and go and leave, and you're diminishing the likelihood that activity is actually going to happen. So I think supporting breastfeeding, for example, is one big one, but I would be interested in hearing from you all on, you know, we know about the lighting and the circadian rhythm and the lighting is really critical.

 

the acoustics and making sure that it's not too acoustically isolated. We don't want to eliminate all of the noise, but we also can't sustain, you know, those babies can't handle the stress of too much alarming and noise. So there are a lot of design strategies that we can do, whether it's specific equipment that we design the system to alarm.

 

in a certain way, whether that's a buzz instead of a ring, or whether that's a light instead of a noise. But there's also still a lot to learn. But generally, what you'll see in the journal, the Heard Journal, let me see, it's Health Environments, Health Environments Research Design. That's a journal full of literature

 

Daphna Yasova Barbeau, MD (she/her) (43:05.538)

Mm-hmm.

 

Sarah Walter (43:23.007)

articles around the built environment and how that built environment supports better patient outcomes or clinical operations. And a lot of those articles are around controlling elements around lighting, acoustics, temperature, falls, hand washing, and how to encourage better hand washing practices, and how to encourage safer hand washing locations.

 

For example, we don't want the hand wash sink, we want one in every room, but we don't want one in every patient room, but we don't want one at the patient's head because there's a risk of that splashing getting over to the patient. So I think a lot of the design research that you'll find is responding to clinical research that's finding that there's certain environmental conditions that support or don't support patient...

 

recovery.

 

Daphna Yasova Barbeau, MD (she/her) (44:24.438)

Yeah, go ahead then.

 

Ben Courchia MD (44:24.535)

What's interesting to me is that I forget which in the context of which war it was where the New York Times had something on like torture. And they said how they put like prisoners in like a small space. They turn on the lights for 24 hours a day and they just give loud noises. And I was reading this article and I was like, that's not dissimilar to what we're doing to our patients in the ICU. Lights are on 24 seven. There's alarms blasting 24 hours a day and we're supposed to give them

 

Sarah Walter (44:42.286)

Yeah.

 

Daphna Yasova Barbeau, MD (she/her) (44:42.506)

Yeah.

 

Ben Courchia MD (44:50.647)

a neurodevelopmentally appropriate environment to thrive. And so when you're asking what are our thoughts, I mean, I think it is critical for us to design spaces that are more, I don't know, more family oriented, more maternal than what we are currently doing because it's sometimes, especially if they're not champions around the unit to make sure like in our unit, Daphna is our decibel and lightning police.

 

Daphna Yasova Barbeau, MD (she/her) (45:18.974)

But I mean a lot of resistance.

 

Ben Courchia MD (45:20.623)

But what I'm saying is that if we don't have these agents that are making sure that we're trying to do the best we can for our babies, it is atrocious what we subject them to. It's atrocious. And like you said, God forbid, there's a baby, if you're in an open Bay area and there's a baby that's having a code or something, then lights are on and it's just everybody is awake, right? I mean, it's, so I could not agree with you more. Sorry, Daphne, you were going to ask something.

 

Daphna Yasova Barbeau, MD (she/her) (45:43.029)

Mm-hmm.

 

Daphna Yasova Barbeau, MD (she/her) (45:47.978)

No, no, no. I think why this is so important in the NICU, even though it is the trickle down effect, right? It is the space where I think this has been at least studied, even though we have some real pioneers in the field and who did really early research to help us know these things. There's still not the standard of care in most units, but I think that's the NICU such as important place because like the PICU or...

 

the adult ICU, hopefully those patients get a little bit better and then they move down to the step down or to the floor where the space is different and it's built for that type of patient. And then they eventually hopefully go home and we have this population that are critically ill and growing and developing and this tiny...

 

malleable brain is really just like starting to make its connections where we do a lot of negative connections in the NICU based on, you know, I won't reiterate all of the things that you said. I think Ben gave the perfect example. We're basically torturing our babies and the parents, right? The parents are feeling that stressful, chaotic environment and we don't even talk about like.

 

what that does to staff over decades and decades of work. But if we just focused on our patients, it's such a special population where we need to, we need to design a unit that is, like you said, comforting and welcoming to families, right? Because that's how we get the best outcomes, is if we have parent partners and they're engaged in the development process.

 

And we have to have the safety and infection reduction, and we have to have the space built for codes. And we are still, I think, where we lack is how do we not just, I mean, right now, we're just learning to mitigate some of this noxious stuff, but can we design environments that actually provide positive stimulation for babies? And so I don't know if the, I mean,

 

Daphna Yasova Barbeau, MD (she/her) (47:51.274)

I do know the literature is scant in that area. And I wonder, you know, what, what is the future of that? How can people who are maybe early in their careers are still in training who are like, that sounds interesting. Um, engage in that kind of work.

 

Nora Colman (48:08.01)

So I think that's a great point, Daphna. And there's so much, I mean, as the advancements in care delivery or the needle continues to move forward in NICU care, it also needs to parallel that with advancements in design, which is why we love to talk about this like cross industry, like why talking with you and talking with Sarah is such an important opportunity to really understand the needs and then be able to drive those, to meet those needs and mitigate those risks from the...

 

design standpoint, I think one of the biggest challenges is that doing what's safer and better for our patients oftentimes pushes clinicians outside of their comfort zone, right? Like we are very comfortable in the way that we've always done things, right? So I think again, open beta private rooms is a great example of pushing a clinician far outside of what they're comfortable with. But thinking about those, you know, elements like the private patient room gives families time to be actually at the bedside with their

 

babies, right? It promotes, now you don't need a lactation room for moms to go to, they can pump inside the room. It gives privacy. It reduces stress because, you know, if you're coding a kid in another patient room, like that parent should be isolated in their other child's room and not exposed to the noise and the chaos that's evolving in the hallway. Thinking about closing off those rooms and then minimizing...

 

cross contamination, which puts your babies at super high risk for infection. Like where are your sinks? Where is your splash zone? Where are you preparing milk? Right. But how does, like, if you're preparing milk inside the room, how does that impact your operational model about where milk is delivery, delivered and prepped? And is it cleaner if your sink is in the wrong location? It might not be. So

 

We really have to balance what we're used to as clinicians and providers with what's better and safer our patient and be able to move the needle forward by kind of letting go of some of our own things that keep us comfortable. But there definitely are, I think, more opportunities for aligning design with the need for improving outcomes with developmental.

 

Nora Colman (50:15.674)

meeting developmental milestones. There's literature about like, where are your windows? Like they need light, but not too much light. There's a lot of work now around the impact of the, and maybe it's not new, but it's new for me, around the impact of the environment on your wellness. And so Sarah can talk a lot about interior design too, but like, what is the lighting, the color, the furnishings that impact like...

 

Daphna Yasova Barbeau, MD (she/her) (50:30.899)

Mm-hmm.

 

Nora Colman (50:38.618)

a mother's wellbeing and her mindset, right? And her ability to bond and connect with that baby. How does your room support kangaroo care? Like, is there space for that mom to actually take the baby out of the isolate, hold that baby, but the staff still needs to be able to access that baby in an emergency. So there's so many built environment things that we're doing, but that we can continue to research and think about.

 

so that we can actually optimize our patient outcomes. There's a lot of technology coming down the line too. Like now, as we think about for us in the PICU, like developmentally early mobility, day and night cycling, ICU delirium, we see, we get a lot of your NICU babies and those kids have significant developmental delays, right? So space for PT and OT to work in the rooms and what do they need and engaging them in the design process? Where are your, how do you,

 

Daphna Yasova Barbeau, MD (she/her) (51:20.334)

Hehehe. Mm-hmm.

 

Daphna Yasova Barbeau, MD (she/her) (51:25.806)

Hmm.

 

Nora Colman (51:33.974)

controls in your space so that the families and the patients can actually control lighting and ambient environment. So there's really cool technology in that space as well. And now like people are using VR to help with early mobility and mobility when they can't when they're stuck in the bed and can't get out. So I think that there's, you know, a lot of cross work across disciplines too.

 

that will drive the future of care delivery, especially also thinking about the vulnerability and complexity of the NICU population.

 

Ben Courchia MD (52:05.243)

So it's great that you're mentioning VR, because I was going to ask you exactly that question. Considering that you went the physical route, and you created a hospital out of cardboard and just to create these spaces, do you guys think that this might be transferable through VR just because of maybe the cost that it might require and things like that? And I'm asking that question quite genuinely, because it's not.

 

in the model that you presented at Delphi this year. The model had like furnitures and like, you were gonna bump into something if this was not designed appropriately. And I have not used.

 

Daphna Yasova Barbeau, MD (she/her) (52:44.898)

Yeah, it was a real city. It was incredible.

 

Ben Courchia MD (52:46.691)

Yeah, and I haven't used VR enough to know if that would translate or not, but I'm just curious if that's something you guys have explored or if that's something that you see a promise maybe for the future.

 

Sarah Walter (52:57.003)

It is. We do use VR and it can be very effective, but to your point, there's still a little bit of a gap between the physical space and the VR space and engaging with others. So if you can get multiple people in the room to simulate that real world situation and you can actually bump into each other and you recognize that there is a conflict, then that's good. But a lot of VR...

 

is done in isolation and because it is VR, you're not necessarily fully engaging with the environment. So it certainly can be effective. And in certain situations, it might be the best route, but in some ways, nothing beats the real thing. Even if it's not a high fidelity mockup, if it's not exactly replicating the space, even if it's just tape on a wall and you're just trying to,

 

map out a certain arrangement of equipment or outlets and you're just using tape on a wall that can be effective.

 

Ben Courchia MD (54:01.266)

Mm-hmm.

 

Nora Colman (54:04.318)

Yeah, I think the biggest, like Sarah said, the biggest limitation right now in VR is the ability for multiple avatars to interact with each other in the same space, to really get into that dynamic care complexity and how everybody interacts with each other and the environment and the patient. The place that it can be really helpful is getting clinicians to actually be able to see their space because again, like...

 

Daphna Yasova Barbeau, MD (she/her) (54:19.214)

Thanks for watching!

 

Nora Colman (54:28.458)

2D is nearly impossible, right? We're like, I don't, this means nothing to me, right? If you look at a architectural drawing, a simple mock-up is a little bit better. High fidelity is great, but like you're still in cardboard walls, right? And so like, there's no, like the doors and the hinges like don't exist. And so then there's like furred out walls, like, you know, the walls like stick out. And when you're doing that in mock-up, like people were constantly putting equipment, like flush against the wall. We're like, it, you.

 

Daphna Yasova Barbeau, MD (she/her) (54:33.654)

Hehehehehehe

 

Nora Colman (54:56.178)

like there's something, there's like a column there, you can actually put your equipment there. And so when we put some of our clinical end users in VR and they were like, oh, that's what this is gonna look like. And so there's still like a layer of fidelity that VR can offer. I think that...

 

The AI or the augmented reality is also like something super interesting to use because you don't have to get in a VR goggle. Like, I don't know if you guys have ever been in VR, but it takes me like...

 

probably 20 minutes to like just move things around and then my feet are like on the ceiling. And so it's not very user friendly. You also have, you almost have to be somebody that plays video games to really interface with it easily. And that's not me, but AR is a little bit easier to navigate because you don't have to put goggles on and you're kind of like walking through the space and seeing what it would look like when you, like when you open the Target app and you put like a couch in your living room. And so it's a great way for clinicians to,

 

Daphna Yasova Barbeau, MD (she/her) (55:32.963)

Hehehe

 

Ben Courchia MD (55:53.095)

Mm-hmm.

 

Nora Colman (55:57.77)

to even be able to imagine their space in a more realistic way than a mock-up.

 

Daphna Yasova Barbeau, MD (she/her) (56:06.246)

I know we are nearing our end of time here together and you guys listed a few resources that probably our NICU professionals are not aware of. But where can people go to learn more?

 

Sarah Walter (56:24.111)

There are a lot of resources, and I think that you all probably have access to a lot of them. It's just when you're looking in your, you know, Journal of Perinatology, if you search for environmental things, so like NICU lighting, or single patient rooms, or hand wash sinks, you'll start to see that it is woven in there. But there's also a number of resources that are dedicated to the physical environment and care.

 

So the Center for Health Design is a great resource. The Herd Journal, Health Environment Research Design Journal is great. That's really focused on health environments and research around it. There's also a great resource, this recommended standards for newborn ICU design. I think the latest edition is 2019. So that's great. And a lot of these things have sort of been adopted in,

 

the Facility Guideline Institute or FGI. So if you're designing a new facility, you'll probably hear FGI thrown around a lot. And FGI does a really nice job of kind of culling through a lot of the latest and greatest research and recommendations and incorporating that into the guidelines.

 

Ben Courchia MD (57:42.423)

My last question for you guys is, let's say somebody is listening to this episode and is just falling in love with the idea and it's like, man, this is phenomenal. I'm going to take this on. Um, and let's say this is some regular individual working in a unit. There's no massive construction plan. There's they're not at the right place at the right time. It doesn't matter, but what is your first step? What is, what is in your opinion, uh, the best advice you could give them saying like,

 

maybe get started there and then move from there to more ambitious things.

 

Nora Colman (58:18.97)

I would say if you could start thinking about your system through a different lens, you've already conquered half the battle. And I'm always happy to share resources, like how do you debrief clinical teams? How do you think about your system differently? And then if you start to engage your medical director and your division chief into really investing some time and energy into thinking about systems of care, that's the...

 

place to start so that when you, if and when you actually have an opportunity to renovate or build a new NICU, you can say, hey, listen, we've already doing this type of work around systems of care and thinking about operations differently. Like this will, this is, you're already creating that framework to kind of think about your work, your work environment and care delivery differently.

 

Daphna Yasova Barbeau, MD (she/her) (59:08.046)

I love that. I wanted to put a plug in, especially for our neonatal community, for people who are interested and want to meet the other people who are interested. I think the Gravens Conference, it's the meeting on the environment of care for high-risk newborns and their families each every year in March. This year, 2024, it's March 6th through 9th in Clearwater Beach, Florida.

 

But they have a work group that meets every year just to talk about the standards of NICU design and some developmental care standards. So I think that's a great conference for fellows to go and learn. They have Fellows Pricing. It's one of my favorite conferences every year for this reason, but I think people will be able to learn a lot.

 

Maybe you guys will join us there one year. Yeah, I think that would be a great place. Are there other conferences specifically for this type of work?

 

Nora Colman (59:58.602)

That would be great. We'd love that.

 

Sarah Walter (59:59.643)

That would be great.

 

Sarah Walter (01:00:08.731)

There are, and finding one that's specific to NICU might be a little bit more challenging, but there are a lot of conferences and industry organizations that you can sort of tune into and they'll host conferences or even webinars. The Center for Health Design actually does a lot. They have a lot of webinars throughout the year and several conferences as well. I'd love to pull a list together and share that.

 

with you all, but there are certainly a number of other resources.

 

Daphna Yasova Barbeau, MD (she/her) (01:00:45.482)

Yeah, we can potentially post them to the show page after this, that would be great. That would be great.

 

Ben Courchia MD (01:00:48.459)

Absolutely.

 

Nora Colman (01:00:50.558)

Yeah. And your listeners are always welcome to reach out to Sarah and I. I think the, you know, what we really hope that everybody gets out of this is just feeling empowered that you have a voice in your environment and really to partner with your hospital executives and with your architect team to really be a part, engaged part of the design process, because you know, what you say matters. You want to have a space that really works for you and is safe for your patients. But if you don't,

 

know that the environment matters, you'll never have a seat at the table. And so we're happy to collaborate, whether it's research or just helping you guys get started, always accessible and happy to share tools and information.

 

Ben Courchia MD (01:01:33.608)

Absolutely. Nora, Sarah, thank you so much for making the time to be on with us today. This was a very enlightening conversation, the topic that we don't talk about very often. So very happy that we had the chance to chat with you for an hour on this. And we will leave all the resources on the episode page. Daphne is already texting me a bunch of links on Slack. Let me wrap up before you slam me with a bunch of texts. And yeah.

 

Daphna Yasova Barbeau, MD (she/her) (01:01:58.07)

I don't wanna forget.

 

Ben Courchia MD (01:01:58.383)

So and we'll leave your email address as well so that can be on there as well. So thank you both very much for your time.

 

Daphna Yasova Barbeau, MD (she/her) (01:02:05.39)

Thanks so much.

 

Nora Colman (01:02:05.482)

Thank you for having us.

 

Sarah Walter (01:02:06.188)

Absolutely, thank you.