Rules, bans, restrictions in healthcare facilities Improving the quality of care for patients is the main goal of every healthcare facility. Satisfaction of patients with medical and nursing care is one of the indicators of quality. Patients have not only rights but also duties. Among other things, patients{\crq} duties include compliance with rules, bans and restrictions during a visit to healthcare facilities. This particularly concerns compliance with therapeutic rules, instructions given by a physician and other limitations associated with the operation of a healthcare facility. The main objective of this diploma thesis was to identify the patients{\crq} attitude and perception of rules, bans, and restrictions, find out how patients observe them and compare the number of rules, bans and restrictions in both outpatient and inpatient healthcare facilities. The data was collected in a survey undertaken in Nemocnice s poliklinikou Praha Italská (Hospital with Outpatient Clinic Prague Italska). This healthcare facility has 2 hospital wards and 31 specialist outpatient departments. A total of 188 respondents took part in the survey (102 outpatients and 86 inpatients). Five hypotheses were proposed. The first hypothesis, which predicted that most patients would perceive rules, bans and restrictions as burden, was not confirmed. The second hypothesis, which predicted that rules, bans and restrictions that were personal would create more stress in female patients than in male patients, was confirmed. The third hypothesis was also confirmed since female patients from outpatient departments of the healthcare facility were shown to be more compliant with rules, bans and restrictions than male patients. Female inpatients from hospital wards of the healthcare facility were not more compliant with rules, bans and restrictions than male inpatients. The fourth hypothesis was not therefore confirmed. Our assumption that inpatients from hospital wards of the healthcare facility are facing more rules, bans and restrictions than outpatients was disproved. The fifth hypothesis was not therefore confirmed. The author has chosen this topic for her diploma thesis because as a nurse she meets different kinds of patients on a daily basis who react differently to rules, bans and restrictions in this healthcare facility. The results of the survey led us to design training classes for nurses and information brochures for patients who visit healthcare facilities. A sufficient amount of information is a basic prerequisite for understanding and complying with rules, bans and restrictions.

Objective: The primary objective of the thesis is to advance proactive thinking in designing healthcare facilities for safety by constructing theory to bridge gaps between evidence-based design (EBD) and human factors/ergonomics (HF/E). Background: Adverse events are a pervasive issue in healthcare, with causes and prevention measures under increased scrutiny for the past 15 years. The physical environment can be an underlying condition of safety and healthcare (HC) facility design can be seen as a layer of defense in accident causation theory. However, HC facility design is complicated and complex, and the implications of decisions can be felt for decades. While architects excel at problem solving, they are not fully versed in healthcare work tasks, flow, and function, resulting in complex system interactions. Evidence-based design (EBD) is a process that uses research as a foundation for decision-making in HC facility design. While the EBD process acknowledges the importance of system factors, its focus is on understanding specific facility design interventions on outcomes such as safety, efficiency, quality of care, and satisfaction. HF/E focuses on humans interacting with a system with a goal of optimizing human well-being and overall system performance. Although HF/E recognizes the physical environment as a system component, the ergonomic definition of the environment lacks clarity and influences are frequently considered at a microergonomic level. In summary, EBD supports desired outcomes of a system through building design, while HF/E more often supports desired outcomes of the system through work design. Methods: The thesis leverages a grant to create a Safety Risk Assessment (SRA) toolkit for HC facility design using: (1) consensus-based methods to develop built-environment considerations for falls in HC facility design, (2) a mixed methods approach to test the SRA in hypothetical scenarios, (3) a mixed methods approach to test the SRA in real-world scenarios, (4) quantitative and qualitative analysis using an inductive and abductive approach to construct grounded theory to develop a core theme and a theoretical framework for proactively considering safety in HC facility design, (5) an extended systematic literature review to identify additional system considerations of the organization and people, and (6) established thinking to advance new theoretical frameworks to achieve the thesis objectives. Results: Two theoretical frameworks are proposed. The first framework, Safety as Complexity of the Organization, People and Environment (SCOPE) is based on the Dial-F systems model (Hignett 2013). The evolution includes: the definition of the ergonomic environment using building design as the most stable element of the system, identifying built environment interventions to mitigate the risk of falls (SCOPE 1.0); the addition of non-building design interventions of the system such as organizational and people-based conditions (SCOPE 2.0); and the integration of HF/E design principles to reframe thinking about hospital falls (DEEP SCOPE). The second framework evolves from grounded theory constructed through data from SRA testing proposing safe design as a participatory process to anticipate, participate, and integrate solutions. A participatory ergonomics framework (Haines and Wilson 1998) is integrated with a mesoergonomic framework of inquiry (Karsh, Waterson, and Holden 2014, Karsh 2006) to advance a theoretical framework of participatory mesoergonomics using the SRA and SCOPE content as inputs over the course of a HC facility design project to achieve safety. Conclusion: The gap between EBD and HF/E can be bridged using safety (falls) as a proactive consideration during HC facility design using theoretical frameworks. These frameworks address (1) the definition of building design and design considerations in the HF/E context and (2) integration of the EBD process with HF/E methods to understand interactions of the system.

La résistance bactérienne aux antibiotiques est un problème de santé publique mondial principalement lié à un mésusage des antibiotiques (surconsommation et prescription inadéquate).Pour lutter contre cette menace, des recommandations diffusées par les sociétés savantes et des plans d’action ont été mis en place. Même si ils sont nécessaires, ils ne sont pas suffisants pour assurer une amélioration significative de l’usage des antibiotiques. Un fort taux de non-conformité de la prescription antibiotique au regard des recommandations est observé dans les établissements de santé (ES). La mise en place de programmes volontaristes de bon usage antibiotique au sein de chaque ES s’avère essentiel pour améliorer l’usage des antibiotiques : une action sur les comportements des prescripteurs est indispensable, par le biais de différentes stratégies. Qu’elles soient persuasives ou restrictives, celles-ci ont toutes montré leur efficacité, sans entraîner d’effets cliniques néfastes pour les patients (pas d’augmentation de la mortalité ni de la durée de séjour), tout en permettant une réduction des coûts liés aux anti-infectieux.Par le biais de nos travaux, nous avons cherché à étudier le bon usage antibiotique en milieu hospitalier, à l’échelle de différents types d’ES (hôpital local, centre hospitalier régional universitaire, cohorte de 259 ES), et en évaluant l’impact de recommandations nationales ou de programmes et de guides locaux. Ces travaux nous ont permis de constater que la diffusion de recommandations nationales pouvait permettre de réduire les consommations de carbapénèmes, et qu’un programme mené dans un hôpital local pouvait être très efficace pour réduire les consommations de fluoroquinolones, mais également la résistance bactérienne à plus long terme. Des audits ciblés sur la prescription des aminosides et l’antibioprophylaxie chirurgicale ont permis de mettre en évidence des non-conformités récurrentes orientant sur des actions d’amélioration ciblées à mener.En conclusion, ce travail souligne l’importance des programmes de bon usage antibiotique au sein de chaque ES, quel que soit le type et le nombre de lits. En effet, ces programmes venant en appui aux recommandations ont démontré leur efficacité pour réduire les consommations et améliorer la qualité des prescriptions antibiotiques, grâce à leur impact positif sur les comportements des prescripteurs. / Bacterial resistance to antibiotics is a worldwide public health issue which is mainly linked to antibiotic misuse (overconsumption and inappropriate prescription).To fight this threat, recommendations from learned societies and national action plans have been set up. Even if they are necessary, they are not sufficient to provide a significant improvement in the antibiotic use. A high rate of non-compliance with the recommendations is observed among healthcare facilities (HCFs). The setting up of proactive antimicrobial stewardship programs (ASP) among every HCF is essential to improve antibiotic use: an action on prescribers’ behavior is necessary, by using various strategies. These strategies, however persuasive or restrictive, have been shown to be effective, with no clinical negative effects for the patients (no increase in mortality and in length of stay), while reducing anti-infective costs.With this work, we aimed to study the appropriateness of antibiotic use in hospitals, at different HCFs levels (local hospital, university hospital, 259 French HCFs cohort), by assessing the impact of national recommendations or local ASP and guidelines. These studies showed that national recommendations could lead to a reduction in carbapenem consumptions, and that an ASP conducted in a local hospital could be very effective to reduce fluoroquinolones consumptions, and bacterial resistance at a longer term. Targeted audits on aminoglycosides prescription and on surgical antibioprophylaxis have permitted to highlight recurrent non-compliances, guiding improvement measures to set up.In conclusion, this work supports the weight of ASPs among each HCF, whatever type and size. Indeed, these ASPs, set up in support of the national recommendations, have demonstrated their effectiveness in reducing antibiotic consumptions and improving prescription appropriateness, by their positive impact on prescribers’ behaviors.

[pt] Os usuários finais de Estabelecimentos Assistenciais de Saúde (EAS) - os pacientes e seus acompanhantes - são, muitas vezes, invisibilizados na arquitetura em saúde. Há, assim, uma distância entre o trabalho do arquiteto e esses usuários, distância que aumenta ou diminui conforme a atuação do profissional. Por meio do método dialético, ou método de Marx, esta pesquisa busca entender e reconstruir a estrutura e a dinâmica dessa distância, analisando as relações que a compõem. A distância é, logo, tanto o ponto de partida quanto o objeto deste estudo. Os componentes da distância, apurados nesta pesquisa e perpassados pela aceitação de Risco como probabilidade de ocorrência de um evento danoso, são: (1) a relação entre arquiteto e contratante; (2) a relação entre Arquitetura e Saúde; (3) a relação entre Arquitetura e Engenharia em Saúde; (4) a relação entre o arquiteto e a Vigilância Sanitária; (5) a relação entre Arquitetura e gerenciamento de manutenção em EAS; e (6) a relação entre Arquitetura e o conceito de humanização dos ambientes em Saúde. Esses componentes nortearam a reconstrução teórica do movimento da distância por meio de análise de entrevistas feitas com profissionais de Arquitetura em Saúde atuantes no mercado privado e na Vigilância Sanitária, bem como por meio de breves considerações sobre a consulta pública que visou substituir a legislação mais importante desse campo de atuação, a RDC 50/2002 da ANVISA. O resultado desta pesquisa aponta caminhos para o aprofundamento teórico e a sistematização do processo de aproximação entre o trabalho na arquitetura em saúde e os usuários finais de EAS. / [en] End users of Healthcare Facilities (HF) - patients and their companions - are often made invisible in healthcare architecture. Thus, there is a distance between the architect s work and these users, a distance that increases or decreases according to the professional s performance. Through the dialectical method, or Marx s method, this research seeks to understand and reconstruct the structure and dynamics of this distance, analyzing the relationships that compose it. The distance is, therefore, both the starting point and the object of this study. The components of the distance, deepened in this research and crossed by the notion of Risk as the probability of the occurrence of a harmful event, are: (1) the relationship between architect and contractor; (2) the relationship between Architecture and Healthcare; (3) the relationship between Architecture and Healthcare Engineering; (4) the relationship between the architect and the state Sanitary Surveillance; (5) the relationship between Architecture and maintenance management in HF; and (6) the relationship between architecture and the concept of humanizing healthcare environments. These components guided the theoretical reconstruction of the distance movement through the analysis of interviews with Healthcare Architecture professionals who work in the private market and in Sanitary Surveillance, as well as brief considerations about the public consultation that aimed to replace the most important legislation of this field, the RDC 50/2002 of ANVISA. The result of this research points out ways for the theoretical deepening and systematization of the approximation process between work in Healthcare Architecture and the end users of HF.