Title: Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation
Funder: Department of Health (England)

Abstract: Since 2001 Department of Health guidance has been that ‘the proportion of single rooms in new hospital developments should aim to be 50% and must be higher than the facilities they are replacing’ [1]. Increasingly new hospital design includes greater ratios of single bedded accommodation and in some cases all single in-patient rooms [2]. There is little evidence from the UK on which to base decisions about moves to single rooms including the private health sector where this model is much more prevalent. This study provides evidence to support benefits to patients re quality and safety of care; and cost effectiveness to the NHS: Single room hospital accommodation is a promising innovation in healthcare delivery and potentially associated with substantial benefits to clinical outcomes and patient experience. However the evidence base for this is limited. The proposed research will provide evidence on safety outcomes and costs (through analysis of pre and post move routinely collected data) at Tunbridge Wells hospital and for other comparator sites. The case study research will also generate evidence relating to changes in working practices (in particular whether single room ward design leads to an increase in direct care time and nurse staffing requirements). Hospitals with 100% single rooms require innovation in working practices to ensure that the potential for improved efficiency and productivity quality and safety and patient experience is fully realised. Patient interviews will explore the impact of single rooms on patient experiences of care and identify the different ways in which single rooms contribute to and create obstacles for patient satisfaction. The proposed research is likely to contribute to improving decision making in relation to single rooms ward layout and optimum working practices to enhance the quality safety and effectiveness of care delivery and will be useful to staff and patients where such changes are planned as well as NHS management policy and commissioning bodies and NHS research users.This theoretically-informed evaluation using lessons from innovation adoption in health service organisations [3] particularly ‘top down’ imposed innovation and how implementation of all single rooms may differ in four case study wards (sampled to reflect different patient groups) re impact upon: care delivery and working practices; staff experience ; patient experience; safety; and costs outcomes. We have ‘before’ routinely collected data and stakeholder interviews and data from four nested case study areas in the old accommodation. We propose collecting the same comparative data ‘after’ the move and plan to also use the before and after data to understand the costs and savings resultant from the single room hospital design.Setting: Maidstone and Tunbridge Wells NHS Trust opened the new Tunbridge Wells Hospital- in 2011 - the first NHS hospital in England to have 100% single in-patient rooms Staff and patients move from a range of old accommodation on two main sites (Kent & Sussex and Pembury hospitals) which comprise large bay and open Nightingale wards. We also propose three other comparator sites for the controlled before and after-quasi experimental study.Data collection: Using a longitudinal mixed methods case study design we propose a realist evaluation with four cases (postnatal ward; acute assessment unit; acute general surgery ward and elderly care ward) within one organisation .Sample sizes for the different elements are provided in the section on data collection below:1. CASE STUDY ELEMENTA OVERALL HOSPITAL CASE STUDY (Tunbridge Wells Hospital)(i) Key stakeholder interviews (n=15-20) to include senior nursing medical allied health professional estates & facilities equipment domestic & catering and ward administrative staff(ii) Routinely collected trust data: relating to workforce (e.g. staff turnover sickness absence); to patient and safety outcomes (infection and falls).B FOUR NESTED CASE STUDIES in postnatal; acute assessment unit; acute general surgery and elderly care(i) Observation of practice: Observation will be undertaken over 30 hours in each case study area (120 hours total).(ii) Staff travel distance captured using pedometers distributed to staff during observation periods. [n=50](iii) Photographs taken by research team of built / working environments (and by staff – see staff interviews below).(iv) Staff survey: to all ward nursing staff in each case study area (n= approx 25-40 in each of four case study areasto complete the survey- total 100-160).(v) Staff interviews: with nursing staff (registered and assistant staff). Total 24 (6 per case study area). Half will additionally involve reflexive photography [18].(vi) Patient interviews: with recently discharged patients. (n= 32-40: 8 - 10 per case study area) Where possible these will include patients who experienced the previous accommodation in phase 1.2. ECONOMIC ELEMENT(i) Nurse staffing costs: compare ward establishments per bed (planned staffing) in each case study ward before and after the move and estimate nursing/midwifery payroll costs per-patient per day.(ii) Overall costs: associated with the two hospital designs (before and after) e.g. costs associated with construction and estimated costs of the nearest equivalent design with 50% single rooms; nursing costs per occupied bed. (e.g. changes in length of stay costs associated infection treatments falls).3. QUASI EXPERIMENT IN COMPARATOR HOSPITALS(i) Routinely collected trust data - patient experience (e.g. patient satisfaction survey) and clinical outcomes (e.g. length of stay hospital infections adverse incidents etc.) to understand how safety outcomes and cost effectiveness differ in different types of wards.(ii) Routinely collected NHS data (e.g. staff survey hospital acquired infection rates local report and score cards) for controlled before and after-quasi experimental study.Data analysis: Qualitative data will be analysed using a framework approach (4) drawing directly on the realistic evaluation framework to guide identification of key themes and example quotations. The theoretical framework will be used to identify general lessons about implementation of the innovation. We will further analyse these data alongside the phase 1 (before move) data – providing a total of 240 hrs observation 48 staff interviews 64-72 patient interviews and 35-40 key stakeholder interviews. This will allow direct comparison with the previous built environment with the proposed business case and with the design plans. Primary analysis for all quantitative data will use appropriate univariate and multivariate tests for difference to make comparisons between ‘before’ and ‘after’. Routine data (e.g. infection rates) will use analyses appropriate for time series to ascertain differences. The implications of single rooms for cost effectiveness will be modelled by developing a number of scenarios for differential costs and outcomes (e.g. improved patient experience changes infection rates) which are plausibly associated with single rooms based on data from other aspects of the study.References:1.Hutton J. NHS Hospitals. House of Commons Hansard 2004;28 Apr 2004(Column 1092W).2.Snow T. Planning the future of ward design. Nursing Standard 2008;23(11):12-13.3.Greenhalgh T. Robert G. Bate P. Macfarlane F. and Kyriakidou O. (2005) Diffusion of innovations in health service organisations: A systematic literature review (BMJ Books).4.Ritchie J. and Spencer L. (1994) Qualitative data analysis for applied policy research’ in A. Bryman and R. Burgess (eds.) Analysing qualitative data (London: Routledge) 173-94.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE