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Journal of Perinatology

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PERSPECTIVE

Reimagining the NICU: a human-centered design approach to healthcare innovation Sabah Mohammed

1✉

, Troy Savage

, Judy Smith3, Mardelle McCuskey Shepley

and Robert D. White5

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Design charettes have been utilized in architectural and design practice to generate innovative ideas. The Reimagining Workshop is a version that combines practical and blue-sky thinking to improve healthcare facility design. The workshop engages diverse stakeholders who follow a human-centered design framework. The Reimagining the Neonatal Intensive Care Unit workshop sought to generate ideas for the future, optimal NICU without speciﬁc site or client constraints. Key themes include family-centered care, technology-enabled care, neighborhood and village design and investing in the care team. Recommendations include a supportive physical environment, celebrating milestones, complementary and alternative medicine, enhancing the transition of care, aiding the transition period, and leveraging technology. The workshop showcased the potential for transformative change in NICU design and provided a roadmap for future advancements. These ﬁndings can inform regulatory standards for NICU design and drive improvements in family-centered care, patient experiences, and outcomes within the NICU environment. Journal of Perinatology (2023) 43:40–44; https://doi.org/10.1038/s41372-023-01794-2

INTRODUCTION For decades, design charettes have been an integral part of architectural and design practice. Charettes have emerged as a particularly valuable format for generating innovative ideas in healthcare design given the intricate nature of healthcare environments and the involvement of multiple stakeholders. The Reimagining Workshop (RWs) is an iteration of the charette that blends practical and blue-sky thinking, incorporating empathy training, and leveraging input from various stakeholders. The reimagining approach can be a catalyst for change, driving signiﬁcant improvements in the design of healthcare facilities. REIMAGINING THE NICU WORKSHOP One notable application of the reimagining approach described by Shepley et al. [1] is the workshop focused on Reimagining the Neonatal Intensive Care Unit (NICU) environment. Rooted in prior charrettes, Reimagining the NICU was a two-part workshop held in person in Spring 2021 followed by a virtual workshop where smaller “super” teams synthesized and built upon the initial ideas generated. The workshop aimed to generate ideas for an optimal NICU without site or client constraints. The workshop comprised 12 groups, each consisting of 8–10 participants, and spanned two half-day sessions with a 1-week gap in between. The workshop planning team carefully selected around 130 participants, including NICU parents, nurses, physicians, designers, engineers, and students. The goals were to ensure that there was diverse participation across user groups and that the workshop centered on participants’ lived experience.

Participants were encouraged to follow the human-centered design framework’s five steps: empathize, define, ideate, prototype, and test. The workshop began with empathy training where participants listened to the experiences of individuals whose infants had been in the NICU. Each group was tasked with formulating a question starting with “How might we…” to guide their pursuit of improvements in patient and family experiences. Groups transformed their ideas into prototypes that were tested, refined, and shared. EVOLUTION OF NEONATAL ENVIRONMENTS While looking ahead, it is important to understand the history of neonatal environments (see Fig. 1). The evolution of neonatal intensive care spaces began with small rooms carved out from newborn nurseries, then evolved into bright, noisy, crowded, and sometimes windowless units [2]. More recently, hospitals have created single-family rooms (SFR) where the parents can reside with their infants, with evidence that SFRs are associated with increased family-centered care, breastfeeding, and parent visitation [3]. However, research has also demonstrated that SFRs are associated with infant, family, and staff isolation [4, 5]. Inherent to NICU admission is an oftentimes-unexpected interruption in bonding between mother and infant [6]. NICU design is continuously evolving in response to research that demonstrates that infants will have better health and developmental outcomes if their physical surroundings support new care models, such as couplet care, skin-to-skin care, and

1 Planning+Strategies, Perkins&Will, Atlanta, GA 30309, USA. 2Mazzetti, Franklin, TN 37067, USA. 3Smith Hager Bajo, Inc., Scottsdale, AZ 85259, USA. 4Department of Human Centered Design, Cornell University, Ithaca, NY 14853, USA. 5Beacon Children’s Hospital, South Bend, IN 46601, USA. ✉email: sabah.mohammed@perkinswill.com

Received: 19 June 2023 Revised: 19 September 2023 Accepted: 4 October 2023

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Fig. 1 A Timeline of the Evolution of Neonatal Environments. The evolution of neonatal environments highlights the collective efforts of healthcare professionals, researchers, and policymakers to ensure better health and developmental outcomes for infants.

family-centered care. The Reimagining workshop aimed to add to this body of research and act as a catalyst for change by driving meaningful improvements in the NICU. The workshop sought to create an environment where different stakeholders could come Journal of Perinatology (2023) 43:40 – 44

together to explore new ideas and challenge existing practices. The overarching goal was to promote family-centered care, enhance the patient and family experience, and improve outcomes within the NICU.

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42 KEY THEMES AND RECOMMENDATIONS During the Reimagining the NICU workshop, participants identiﬁed several key themes and recommendations for improving the design and operation of the NICU. The charette approach resulted in three design prototypes namely familycentered care, technology-enabled care and neighborhood and village design.

iv. Providing a dedicated area to memorialize deceased patients, physicians, and nurses from the unit. 2. Celebrating family milestones a. Implementing visual cues of achievement within the NICU environment to recognize and celebrate the infants’ and families’ milestones.

FAMILY-CENTERED CARE 3. Facilitating access to complementary and alternative medicine (CAM) 1. Designing a supportive physical environment a. Providing spaces for interaction with family and visitors, chairs, and a sleeper sofa for an overnight visitor. b. Designing a NICU that is welcoming and supportive to families is likely to lead to increased family presence and participation in the care of their infant and contribute to improved outcomes. c. Providing family space near the infant’s bedside that includes a comfortable chair for skin-to-skin care, a bed, storage, and a workspace. d. Providing access to private bathrooms is required by the 2018 FGI guidelines. The bathroom can be used by visitors, adding convenience to those providing social support to the mother and infant [7, 8]. e. Providing enough seating options that facilitate interactions with staff at eye level during skin-to-skin contact. Early skin-to-skin contact and suckling have been proven to have benefits for both the mother and child, in addition to promoting bonding [9]. f. Providing hospitality options with supportive resources such as day care facilities and Ronald McDonald Houses. g. Providing shared amenities such as i. A dedicated area for breast milk storage, refrigeration, and milk preparation may reduce the risk of contamination and errors. ii. A small kitchenette with a personal food refrigerator. iii. A personal-size washer and dryer for laundering the infant’s cloth items. The ability to launder items within the room aids in infection prevention [7]. iv. Lounge spaces that include a table and chair set for dining or to be used as a desk; a television; storage and soft seating. This room can also be utilized by siblings for daily activities. h. Promoting a sense of control – i. Giving the family control over lighting and room temperature, operable windows, privacy, confidentiality, and reduction of noise. Research demonstrates that noise reduction is of benefit to patients and staff in NICUs [10–12]. i. Providing access to positive distraction – i. Ensuring that the NICU and support spaces have plants, views of the outdoors, paintings of nature, and soothing music which can be personalized to the patient. ii. Creating dedicated oasis rooms within the NICU that offers respite for staff and families, and are equipped with amenities such as massage chairs, treadmills, music, virtual reality, adjustable lighting, and views of the outdoors. iii. Providing access to outdoor areas such as rooftop gardens or open courtyards. Information about outdoor spaces should be readily accessible to encourage utilization.

a. Providing infant care classes and lactation support before discharge has been shown to have benefits in parental stress and breastfeeding compliance [13]. b. Integrating evidence-based CAM approaches such as reflexology, aromatherapy, kangaroo care and positioning interwoven with the conventional treatment plan. 4. Enhancing the transition of care a. Creating a seamless transition between the hospital and home environment by providing an interim communal home with private rooms and common space. b. Prioritizing ease of transportation from the hospital to the home during this critical phase. 5. Assisting the transition period a. Providing support and resources for parents that empower them to confidently care for their infants at home. Examples include educational materials, a hotline or app, counseling services, and access to support networks. b. Designing systems and processes to enable effective communication and coordination between healthcare providers in both environments. c. Implementing standardized protocols, utilizing electronic health records, and establishing secure informationsharing platforms to ensure the continuity of care plans. d. Equipping families with the necessary knowledge and support, healthcare providers can ensure a smooth and successful transition, fostering a sense of security and well-being for both the infant and the family. e. Including a pediatrician and external healthcare providers in discharge planning facilitates a seamless transition and reduces readmission.

TECHNOLOGY-ENABLED CARE 1. Including a list of key features to be used at five primary locations: patient rooms, nurse/team stations, communal spaces, homes, and provider offices. 2. Providing clear information about the equipment and resources available; helping families understand their purpose and usage. 3. Implementing voice-activated system to answer questions, share visitation information and provide guidance. 4. Providing a full schedule on a shared digital calendar. Participants indicated discomfort and sleep disruptions caused by unscheduled staff and lactation consultant visits in the first few days of being in the NICU. 5. Ensuring technology interoperability to promote seamless integration, communication, efficient data exchange, and Journal of Perinatology (2023) 43:40 – 44

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43 enhanced collaboration among care providers. 6. Providing access to a centralized patient health record as the single source of information for the care team. This can streamline information access and improve efficiency during patient transfer and shift rotations [14]. 7. Providing a dedicated screen for videoconferencing with family or friends in the event of high acuity/isolation level. a. Incubator video monitors give families, especially extended family members who are unable to physically be present at the hospital the ability to see the infants. b. Having built-in Bluetooth speakers with maximum volume not exceeding 65 dB can allow families to play music, and voice recordings. These devices also increase the infants’ exposure to their caregivers’ voices. c. Digital staff boards that display the images and names of attending staff members. This signage helps to eliminate stress and increase comfort with care staff [14]. 8. Enabling virtual rounds using handheld devices and integrating patient health record systems with the team and family. This enables healthcare professionals to remotely connect with families, conduct rounds, provide information, and schedule appointments, ensuring effective communication and engagement. 9. Providing electronic medical charting to enable families to chart feeding times and quantities, diaper changes, and communicate concerns with doctors. This chart can then be accessed by the care team without having to disturb the family. 10. Creating a centralized workflow system that can track medical equipment, nursing staff, custodial staff, doctors, and patients on a single platform leads to improvements in efficiency during patient transfer and shift rotations. 11. Implementing smart boards, and personalized wristbands to improve communication, efficiency, and safety within the NICU. 12. Implementing technology for wayfinding such as informational holographic signages can assist families in navigating the NICU. 13. Exploring the use of AI for deeper insights into the care team and effective communication and security measures. 14. Integrating patient monitoring and behavioral health systems can establish a continuum of care beyond the hospital, ensuring compliance with treatment plans postdischarge [14]. This can also be leveraged to ensure compliance with the treatment plan well after discharge from the hospital. 15. Creating a hotline or app that allows families to easily communicate with the care team, report treatment information, and seek guidance even after leaving the NICU. Conversely, there was also growing consensus among participants on the pitfalls of relying on technology for all communication and replacing a more hands-on approach. 1. Reducing reliance on screens and increasing hands-on care. 2. Encouraging verbal documentation can enhance communication between healthcare providers and families. Parents should be empowered to ask questions such as “What should I do?” and “What can I do?”. 3. Communicating measurements to families, allowing them to actively participate in their infant’s care.

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NEIGHBORHOOD AND VILLAGE DESIGN 1. Prioritizing the family as the center of care through a neighborhood and village design concept with features that are adaptable to existing and new NICUs. 2. Creating spatial hierarchy using furniture or wall positioning to allow for different activities and people to coexist in these shared spaces, affording choices for families according to their preferred interaction in the space. 3. Designing for adaptability a. Ensuring layout flexibility—due to the different levels of privacy needed during social interactions occurring in family support rooms, layout flexibility was recommended in the design of NICU spaces with a shared kitchen, living room, and play area. b. Providing mobile furniture and vertical partitions that can adapt to different group sizes involved in social interactions and to different levels of personal space desired by family members. c. Designing for flexibility depending on acuity level (low acuity to isolation level) to adapt to surge conditions, programming spaces for multipurpose use, or designing “flex” spaces. d. Installing a flexible headwall that can be moved bedside or away when needed for medical procedures or care of the infant. This innovation will potentially allow mothers to stay in bed and interact with their infants. Further research is necessary to design and engineer a movable headwall. e. Designing ergonomic spaces for staff and patients of size at the bedside and charting areas f. Providing flexible patient rooms for multiple needs including rooming in, multiples, hospitalized mom, and family and discharged mom. 4. Designing patient pods that are inspired by urban design principles of the interface. Patient pods include “porch” concepts that can serve social interaction and privacy and other features were shown for staff areas. 5. Establishing visitation programs a. Providing dedicated spaces and training opportunities for relatives to participate and contribute to the care of the infant. b. Engaging extended family members by increasing support, shared responsibility, and strengthening bonds, ultimately enhancing the overall care experience for the infant and their family. 6. Designing decentralized staff stations or ‘satellite stations’ outside patient rooms may improve patient safety, staff burnout and nursing satisfaction. A central touchdown station is still necessary where nurses can collaborate when they are not at the bedside.

INVESTING IN THE CARE TEAM In addition to the above themes, another sub-theme emerged. 1. Creating an environment for continuous development by providing spaces such as simulation rooms for training and up-skilling. 2. Establishing a research program that empowers residents, interns, and nurses to research process improvement in the NICU.

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44 3. Establishing systems and processes that promote ongoing education and knowledge exchange among healthcare professionals such as regular educational sessions, journal clubs, case reviews, and collaborative discussions that encourage sharing best practices and exploring new research and advancements in neonatal care. 4. Adding visual cues that celebrate staff achievement and promote a sense of accomplishment. 5. Flattening the organizational hierarchy to facilitate more communication channels between the care team members. 6. Designing spaces that support staff health such as a nap room, an oasis room, and an exercise area. 7. Incentivizing departmental performance across various metrics such as infection control, patient satisfaction, and length of stay (LOS) by rewarding the care team appropriately for every milestone achieved. The key themes identiﬁed during the workshop underscored the importance of a comprehensive approach to reimagining the NICU and providing a roadmap for future advancements. CONCLUSION The results from the workshop are intended to inform regulatory minimum NICU design standards and demonstrate the power of collaborative efforts in driving transformative change in neonatal care environments. The recommendations generated during the workshop should be considered and further studied to improve NICU design and models of care. Some of the recommendations require further research to establish safety and efﬁcacy. By implementing these recommendations, we can create NICUs that foster a nurturing and supportive environment for the most vulnerable members of our society. It is now incumbent upon healthcare organizations, policymakers, researchers, and designers to heed the call to action. Together, we can reshape the future of neonatal care and make a lasting impact on the lives of countless families.

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AUTHOR CONTRIBUTIONS SM—collected the data, contributed the data and tools, performed the analysis, wrote the paper. TS—collected the data, contributed the data and tools, provided edits to the paper. JS—collected the data, contributed the data and tools, provided edits to the paper. Dr MMS—collected the data, conceived, and designed the analysis, provided edits to the paper. Dr RDW—collected the data, conceived, and designed the analysis, provided edits to the paper.

COMPETING INTERESTS The authors declare no competing interests.

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Journal of Perinatology (2023) 43:40 – 44