Summary: For the last five years, a Belgian hospital has been searching for innovative ways to optimise their operations in care and supporting processes. From motion sensors and tablet PCs used by the cleaning service, to Bluetooth-based asset and patient tracking, to robotics and wearables – these are just a few of their promising projects discussed in this article.
AZ Maria Middelares, located to the south of Ghent, Belgium, is a medium-sized institution with 542 licenced beds and 99 beds for same-day care. 1,850 medical staff and over 200 physicians attend to 150,000 patients per year. The hospital’s reputation is based on services and disciplines such as cardiology and heart surgery, its Ophthalmology Centre, its integrated Cancer Centre, physiotherapy (with interactive programmes and a spinal unit) and its Foot Centre, the biggest in Flanders.
In 2016 and 2019, AZ Maria Middelares received accreditation from the American Joint Commission International (JCI).
Leading the Facility Management and Safety domain in the hospital, I am responsible for cleaning, food/catering, stock management, medical equipment, safety and purchasing. My work contributes to different strategic objectives of the hospital, including high-tech expert care, innovation and research, quality-assured patient-oriented care, stimulating working environment, strategic partnerships and financial health.
In April 2015, AZ Maria Middelares moved to a brand-new hospital with high-tech infrastructure. The move had required extensive preparation and not only in physical terms. In fact, a new organisation had to be developed with new processes, functions, teams, tasks, etc, and this was initiated as early as 2012 with the focus on technology in both infrastructure and operations.
The hospital has been Wi-Fi-covered from the beginning, and at a later stage the Bluetooth network was added. The electronic patients file has been in place since 2008.
From Automated Lighting to Occupancy Measurement
Many rooms (offices, meeting rooms, waiting rooms, etc) in the hospital are equipped with motion sensors. They contribute to energy saving, eg the light is automatically switched off when no one is present in the room. This technology has been in use since 2015. Back then we didn’t think that the sensors also provided valuable information, but now we are trying to utilise them in the broader space monitoring, eg to measure the space occupancy.
One novel application is in cleaning service – the sensor data provide insight into how frequently spaces are used, which ones require cleaning, etc, and our cleaning department was very interested.
In June 2019 we brought together several companies – the one that provided the motion sensors, the one that installed the automated lighting control, the building management one and the data management one – and tasked them with connecting all those elements in order to measure the occupancy of the space, from wards to toilets to meeting rooms. By September 2019, we had a proof of concept for a platform integrating all the sensors’ data to optimise the use of the space through advanced data analysis. Now we are in the process of collecting the necessary amount of data to see the full picture, and once that is done, we will integrate this process into our software for cleaning.
In 2019 we fully digitalised our cleaning services. All cleaning carts are now equipped with tablet PCs (Figure 1). There is an interactive digital map of the hospital in place. The cleaning team, therefore, has a full picture of the work needed to be done at any given moment and autonomy in planning this work. This year we will add the occupancy tracking module in their system.
It should be noted that before we introduced this technology, we had processes in place, which we first optimised through discussions with nursing and cleaning staff. These were later refined with technology increasing efficiency and helping the staff to self-manage their work.
One such process concerned discharge when a patient room needs to be cleaned before the next patient is admitted. Previously the communication was done with paper notes, by phone or email, and the system was chaotic. In 2017 we analysed and mapped the process, and together with an external partner used the data on discharges from the EHR to develop a platform. It could, on the one hand, withdraw the discharge notification from the EHR and, on the other hand, generate a prioritised task list for the cleaning staff. The communication was based on codes, and gradually the written and phone interactions were phased out.
Also, the system saves time since there is no need for nurses to handle the discharge reporting – it is registered automatically and can be checked in the system at any moment.
Now each member of the cleaning team can log into the system with their personal badge to see interactive floor plan of the hospital, checklists with tasks, overviews of tasks per room. Illustrations provide additional information, for example, if a ‘wet floor’ sign is placed correctly (see Figure 1).
The latest addition is an autonomous cleaning robot, which we call ‘Broom.’ We are the first hospital in the EU to have a robot assisting the cleaning staff in their duties – and they are happy to share the work with it.
Another important issue is the adoption of this new technology by the staff. There were doubts initially about whether they would be able to handle the tablet PCs. However, with the internal training all of them are now not only capable to use the system but also feel very enthusiastic about it. They were trained by their own management, who also work on the floor and know the processes – this was a big advantage. Plus they now have access to the intranet, can report issues, register for additional training, etc.
In other words, the technology benefits the general wellbeing at work. There has been, for example, a sharp decrease in absenteeism rates and an increase in retention rates, and a very positive dynamic of collegiality has developed among the cleaning staff.
Culture of Help
This is part of our culture – we are not controlling, we are helping. And if you help the staff, they start helping each other. With the new system they have information on the overall amount of work and each other’s workload, and the management don’t need to tell them to do their job anymore – they take the initiative and work as a team helping each other. They say, “I will do the job if a colleague is busy.”
Of course, this is partially due to the kind of people we hire. Good cleaning staff is really hard to find. They need to be team-oriented, friendly, willing to work. As they interact with patients, they also have to speak our language – personal contact is a very important element of the overall patient experience.
Since 2018 we have been collaborating with the state employment agency to find the right people for professional cleaning in healthcare. After recruitment and selection by the agency and a 14-day internship in the hospital, people with the right motivation and values are offered a permanent job. This process takes a lot of effort, but it is worth it – we get the best of the best. Appreciating this, we are continuously developing tools to help them to do their job, but also to ensure they like it. This is an example of not only technological, but also social innovation.
As I have already mentioned, we have a hospital-wide Wi-Fi network. It was installed in 2014–2015, and upgraded in 2019 due to security reasons. As part of that upgrade, we complemented each Wi-Fi antenna with a Bluetooth module, which allows for the hospital to have Bluetooth coverage as well. As a result, we started testing and integrating hardware and software components that can track and trace various assets in real time via the Bluetooth protocol (Figure 2).
Our first project focuses on the 2,500 surgical instrument sets. These sets are constantly circulating between the operating room and the central sterile services department, and the rotation rate of a set is very high. Sometimes the precise location of sets was difficult to identify, for example, because of incorrect labelling or storing the set in a wrong place.
We saw the asset track-and-trace system as a solution to this problem. Our options were passive RFIDs, which couldn’t be used hospital-wide, or active RFIDs with Wi-Fi tags, which are expensive. Another challenge was that tags are frequently exposed to very high temperatures and humidity during the sterilisation process, so they needed to be autoclave-resistant enduring the temperature of 135ºC for 1 to 2 hours.
Eventually we had found a company willing to develop an autoclave-resistant active RFID tag using Bluetooth protocol, which made it possible to be applied hospital-wide at a much lower cost.
The project began in January 2019, and by the end of Q3 2019 we had a proof of concept for the system. It enables us to track and trace any asset that has a tag on it, be it a smartphone, a keyboard or an infusion pump. The system now works for a small part of the surgical instruments sets, and in 2020 we are planning to expand it to medical equipment and other assets, to be able to locate the devices quickly and to map their utilisation patterns. Analysis of these data would allow us to better assess the equipment life cycles, manage it more efficiently, and adjust our investments.
For now the track-and-trace systems are internally-focused (we are also looking into the possibility of installing an alarm for when a tag-equipped item leaves the hospital territory). There is no tracking beyond the hospital, but we are already in discussions with partners and suppliers about using Bluetooth tags for their assets, such as carts or instruments, for us to be able to track those. For this we need to develop an open cloud-based platform to store the data, so that other hospitals and vendors could use them.
Another project being discussed with our physicians working in the operating room and surgical department is tracking of patients. Initially we want to run this in the surgical day clinic tracing as the patients come in the morning, go to the waiting lounge, prepare for anaesthesia, have the surgery in the operating room, then recover and go back home. We hope to have this system in place by Q2 2020.
At a later stage certain data points (checkpoints) can be automatically added to the EHR combined with identification by nursing staff. This would provide us with a more accurate, comprehensive real-time view of a patient’s route in the hospital and help to optimise the process, eg reduce waiting times for patients and eliminate the delays caused by the manual recording of these data by the staff.
The data could also be shared with a patient’s family so that they know at which treatment stage exactly is their beloved one. This is a very important and delicate task as we need to decide on the specific information we would provide to the patients and their families. We must find the most friendly and correct way to do this.
This process would be a combination of personal communication (by a nurse or a physician) and technology. On the latter part this will be done through personal health records – a secure digital platform, to which patients and their families would have access. Hopefully, we will start testing this platform sometime in June-September 2020.
Several years ago our CEO introduced what we call Innovation Cells. They are small multidisciplinary teams of innovative specialists – physicians, engineers, nursing, ICT, administration staff – that meet every two months to get new insights and ideas and give feedback. With the special innovation budget allocated, they can initiate, discuss and run various pilot projects, involving external partners if needed. Every project follows certain principles, such as ethical responsibility, safety, accessibility, and is assessed by applying five key criteria, namely:
• Better clinical outcome.
• Better patient experience.
• Higher staff satisfaction.
• Overall value/risk for the hospital.
At the moment there are three Innovation Cells.
Wearables/mHealth deals with biosensors (automatic EWS registration), telerehabilitation (moveUP) and smart asset tracking.
Digitalisation/automation/robotics focuses on automatic guided vehicles (AGVs) for delivery of goods, medication or operating sets as well as patient transportation and drone deliveries; 3D printed implants; and robotic process automation (billing and biotech records).
AI/Big Data/AR/VR is involved in development of a virtual hospital (virtueelziekenhuis.be); the Hololens project (holographic animation used to provide additional visual information during procedures and for patient education); and medical data warehouse among others.
One of the recent discussions in Innovation Cells concerned automation; there was a presentation on introducing robotics into our logistics. AGVs are already in use in many hospitals around the world, eg in Italy, the Netherlands, the U.S., but usually those hospitals have been specifically designed with AGVs in mind. That is not our case, so we need to find a tailor-made solution and at the same time introduce some substantial technical adjustments, such as in lift and door design.
Following the initiative of an Innovation Cell, we have also partnered with a company to introduce wearables into the clinical assistance process, for an early warning score (EWS) procedures automation. Since 2012, every patient’s vital signs, such as respiratory rate, temperature, blood pressure, pulse/heart rate, AVPU response, are systematically monitored three times every 24 hours. If the patient’s condition deteriorates, the measurements are performed every 30 minutes. Thus we always know the status of the patient and are able to identify trends and predict whether a crisis is coming.
The wearables pilot project is implemented among patients with EWS scores of 3 or 4, of which approximately 22% usually are directly transferred to a higher level of care – this is currently the best, but also the most expensive solution. And we hope that wearables would help us to decrease this share as they allow for the patient to be constantly monitored while being in their ward. Over the last five years, we have managed to decrease the number of reanimations by 80%. The irony is that we are losing financially as a result, no longer being paid for these complex procedures. But the quality of care always comes first for us, so we view it as a benefit.
In addition, wearables provide more freedom to a patient (eg for an independent visit to a toilet) and simultaneously unburden the nursing staff, who no longer need to neither perform the time-consuming measuring procedures nor frequently accompany the patients, and let them optimise their schedules. Wearables also alleviate stress in patients who know they are being constantly monitored.
The fact that the data from wearables are automatically recorded in the EHR means that chances of errors or misinterpretation are nil, and hence the overall risk is decreased. In the future we plan to install dashboards to have the overview of all these data. Another addition is a contact-free monitoring system (a membrane plate with sensors) to detect the motion-related fall risk in immobilised patients and provide continuous control with a more limited number of parameters. We have been testing it since Q4 2019 and are now expanding it.
Smart vs. Traditional
There is a fine line between traditional and smart building management. There are systems which measure temperature, humidity – we think of those as traditional systems. However, you could extract the data from those systems and apply it in a novel, ‘smart’ way – such as we do with the occupancy measuring project. Smart building management is more about work processes and experiences, and the means used for their optimisation could easily be found in traditional systems. In other words, traditional and smart become integrated to improve overall experience for patients, visitors, staff, etc.
- Moving to a new hospital was not only physical but also required a profound organisational change.
- The motion detection system will be used to measure the occupancy of the spaces. These data will help the cleaning service to have a clear view of the workload.
- Cleaning staff were successfully trained to use the new digital system. The technology also inspired the development of a culture of help among them.
- Asset tracking promises to become a solution to a number of issues in the hospital. Bluetooth tags allow to use the system hospital-wide and to scale it beyond the hospital walls.
- Patient tracking is hoped to optimise the clinical assistance and provide data to be shared with patients and their families in a friendly and considerate way.
- Three Innovation Cells are an effective way to test innovative solutions. Latest examples include introducing AGVs and using wearables for patient monitoring.
- Smart building management is not an isolated practice. It is built upon and tightly integrated with traditional management systems.