Healthcare Facility Planning Tools and Guidelines
Spring-Summer 2017Volume 10, Number 2
IN THIS ISSUE
By Cynthia Hayward
A shelf full of outdated facility master plans is a common sight in the facility manager’s office of a large healthcare system. These are often very thick documents with beautiful graphics that explain in great detail the phased stages of a multi-year building project. There are many reasons why these plans may not have been implemented but the planning process itself is a major factor.
To read about static versus dynamic facility master plans and related issues >>
Facility master plans first became common in the era of cost-based reimbursement and when the acute care hospital was the primary setting for patient care. With unbounded growth projected, every hospital needed a “master” plan to ensure that the next building wing to be constructed did not preclude subsequent expansion options in the future — thus preventing the site from becoming “landlocked.” The traditional process focused on evaluating architectural options and prescribing a multi-phased solution to prevent disruption of critical hospital operations and to align with the availability of capital dollars; a 20-year planning horizon was not unusual.
Over time, the development of a long-range facility master plan has become a lot more complicated. The evolution of multi-hospital health systems, continuing gravitation of outpatient care to lower-cost offsite settings, and deteriorating financial condition of many hospitals are key factors. According to the American Hospital Association, about two-thirds of all community hospitals are now part of a healthcare system (AHA 2016). It is rare today for a facility master plan to be developed for a single hospital campus without considering the strategic (market) plan, clinical service integration initiatives, physician recruiting, and various other strategies of the health system as a whole. Moreover, each campus must not only compete for dollars for facility upgrading and expansion, but hospital management must evaluate the trade-offs between investing in facilities versus new medical equipment, information technology, buying physician practices, and the like.
Expansion of services does not always result in new construction but may involve leasing space, creative partnerships or joint ventures with physicians, or investing in new technology that enables care to be delivered in non-traditional settings.
With tightly managed care, reduced reimbursement, and losses from delivering uncompensated services, half of U.S. hospitals are losing money delivering patient care (AHA 2016). This has resulted in dwindling financial resources for investment in facilities. The AHA also reports that the average age of the physical plant for all U.S. hospitals continues to increase and is about 11 years. The lack of ongoing maintenance and investment in infrastructure often results in sticker shock when the hospital leadership is faced with mitigating code noncompliances — leaving little money left for renewal or expansion of existing space.
STATIC VERSUS DYNAMIC FACILITY MASTER PLAN
In the traditional facility master planning process, current space deficiencies and future workload projections are usually translated directly into facility “options” that are represented by architectural drawings. A preferred design solution is subsequently selected. Renovation or construction cost estimates and a phased construction schedule are developed with individual projects identified for funding approval and staged implementation. As part of the implementation of the facility master plan, the design architect is then commissioned to provide more detailed architectural drawings and to prepare construction documents.
The problem with this approach is that alternative operational concepts are often evaluated (if evaluated at all) based on an architectural rendering rather than sound business principles and consistency with specific strategic planning and operations improvement objectives. This kind of facility master planning process where the planning team jumps prematurely into design, with the sole output being an architectural block drawing of planned future department locations and building projects, is no longer relevant given the dynamic nature of the healthcare industry. If market conditions change and workload projections do not come to fruition in such a way that one or more projects prove infeasible, or if department leadership changes, the entire plan is deemed outdated and then is shelved.
The gap between the identification of facility deficiencies and future space needs, and the search for subsequent architectural solutions, should be bridged with a thorough evaluation of priorities and capital investment trade-offs. Consensus on the resulting long-range facility development or “capital investment” strategy, allows the planning team to begin a phased implementation of the facility master plan with confidence. They can readily alter their course as needed to reflect unanticipated changes in the market, reimbursement, regulations, and technology.
A long-range facility investment strategy provides a road map to guide renovation and construction (capital investment) over a defined planning horizon. It helps senior leadership to understand key facility issues and priorities facing the organization and to reach consensus on capital investment goals and objectives. It also aligns facility investments with the organization’s strategic business plan, operations improvement initiatives, planned information technology investments (IT strategic plan), and financial resources. Documentation of an agreed-on facility investment strategy helps to educate physicians, employees, and other stakeholders relative to long-range planning goals and priorities. Unlike the traditional facility master plan, adherence to defined strategies allows for a dynamic process that does not become obsolete if one or more individual projects are derailed.
"A goal is an outcome. A strategy is the approach you take to achieve a goal and an objective is a measurable step as part of achieving a strategy. An action or tactic is a tool you use in pursuing your strategy."
GOALS, STRATEGIES, AND ACTIONS
For example, a healthcare system may have an overall goal to provide additional physician office space on a specific hospital campus to enhance physician recruiting efforts, co-locate specialists who are currently dispersed, and improve customer convenience. The corresponding strategy may be to develop 60,000 gross square feet of new medical office space in a single location on the campus with flexible “time-share” space. The action (tactic) — or architectural solution — may be to acquire an adjacent property and to construct a new medical office building with contiguous customer parking. If the planned architectural solution is derailed — for example, the acquisition of the specific property falls through — then another architectural solution can be evaluated to achieve the same goal. Many facility master plans do not clearly document the current facility issues and the agreed-upon priorities of senior leadership. The absence of defined goals and strategies, that drive the specific actions necessary to achieve each specific goal, makes it difficult to understand the rationale behind the architectural solution.
LEGITIMATE UNFORSEEN FACTORS
There are always unforeseen factors that can legitimately derail a facility master plan. Reimbursement and legislative changes can have a significant impact on capital investment decisions — such as the uncertainly today with the Affordable Care Act subsidies and Medicaid expansion. Priorities may suddenly shift when a competitor launches a new initiative that could impact the organizations market share (and revenue). Likewise, the closure of a competitor hospital my present a new opportunity. The emergence of a private donor who wishes to contribute a significant amount of money for a “pet” project can also derail priorities.
REALISTIC PLANNING HORIZON AND "BUY IN" FROM LEADERSHIP
In today’s dynamic environment, ten years is the typical planning horizon for a “long-range” capital investment plan and it should be reevaluated and updated every couple of years — particularly when there is a change in leadership or when unforeseen factors occur. Buy-in from key stakeholders — the executive team, board members, physician leaders, facility management — is also mandatory if the facility master plan is to be a dynamic document.
Reference: American Hospital Association. 2016. TrendWatch Chartbook 2016. Trends Affecting Hospitals and Health Systems. Washington, DC: American Hospital Association.
IN THE NEWS
According to a new report published by Ariadne Labs and MASS Design Group, the physical design of a hospital's birthing unit may affect its Cesarean section rate. Based on previous research, the team knew C-section rates can vary from 7 percent to 70 percent simply depending on the facility. As many as half of these C-sections are unnecessary and add surgical complications and increase costs. To begin to determine how much the physical layout of a hospital may impact C-section rates, the team chose 12 diverse childbirth locations — three birth centers and nine hospitals. They conducted site visits and phone interviews to develop facility profiles and compare the childbirth locations as quantitatively as possible.
To read about key findings from the report that highlight potential connections between design and efficiency >>
- Higher room demand — or the annual delivery volume per labor delivery room — is associated with higher C-section rates and may contribute to overuse of the surgical procedure.
- Facility size — or the deliveries per square foot of the unit — may be positively associated with higher C-section rates. The researchers noted that when a facility is too big, travel times between rooms can be detrimental to patient care or there is a loss of intimacy reported by patients.
- The distance between patient rooms, the distance from workstations to patient rooms, and large patient rooms all can drive up treatment intensity resulting in increased rates of C-sections. Large rooms can also contribute to this problem, effectively adding to the distance between rooms.
- Room standardization does not affect C-section rates. Despite logically increasing efficiency, the study suggests little to no benefit from creating the same environment from room to room.
- Fewer collaborative spaces for staff may be associated with greater C-section rates. The researchers suggest more collaborative space allows for greater levels of motivation and accountability. However, they note an element of motivation and accountability comes from team culture — it could also lead to more patient monitoring and more C-sections.
- The percent of unit space available for patients to "labor walk" or move around was associated with lower treatment intensity.
Source: “Seven Ways Hospital Design May Affect C-Section Rates” by Emily Rappleye, Becker’s Hospital Review Facilities Management, March 27, 2017.
The entire report — Design Capacity for High Value Healthcare: The Impact of Design on Clinical Care in Childbirth — can be downloaded at the MASS Design Group website.
By Cynthia Hayward
Any healthcare organization would be delighted to have a private donor fund a building project. Sometimes, however, the donor has no interest in the organization’s long-range capital investment strategy but wants to construct a building or fund a program that is not even on its radar screen. Most institutions are not in a position to reject such donations, and it is a rare administrator who has the back-bone to turn down money rather than to compromise the organization’s long-range facility master plan.
To read about the challenges of donated buildings, naming rights, and plaques and signs >>
NEW BUILDINGS AND INCREASED OPERATIONAL COSTS
Particularly when a donation is made for a new building, healthcare organizations should not be deluded into thinking that the donor money comes unconditionally. These projects can become difficult and emotionally draining. It helps, though, if the fundraising arm of the organization is integrated with the facility planning process in such a way that the organization can seek donations that are aligned with its facility master plan. However, the real issue associated with constructing an unnecessary or oversized building is affording the ongoing operational costs, even though the initial construction is financed by someone else.
NAMING RIGHTS WITH STRINGS ATTACHED
Some healthcare organizations solicit donations for the “naming rights” for specific building components such as wings, “centers of excellence” within a building, conference rooms, lobbies/lounges, or high-tech procedure rooms. This can be a source of money for renovating a specific area of the hospital or to purchase a piece of expensive medical equipment. This can, however, get complicated when subsequent renovation is required at a future date or when a donated piece of equipment is no longer state-of-the-art. Sometimes, donors, or their relatives, may demand to be involved in the planning of interior finishes, furnishings, and decoration. In a large institution, this can conflict with the development of a unified “look and feel” as part of corporate branding. Taken to extremes, too much disparate input on interior design can make the facility look like a furniture showroom with uncoordinated vignettes at every corridor turn.
PLAQUES AND SIGNS IMPACT WAYFINDING
It is also increasingly common for healthcare organizations to solicit smaller donations for wall-mounted plaques and signs that recognize the donor’s name. The size of the letters on the plaque and type of material sometimes reflects the amount of the donation as well. These plaques are often located on a feature wall in an entrance lobby or along the walls of public corridors. This frequently results in donor plaque “fatigue” with information overload that impedes wayfinding as the clutter of donor signs obscures necessary directional signs.
THE NEXT WAVE? WHAT ABOUT LABOR COSTS
With operational costs rising, what the healthcare industry really needs today is sponsorship of nurses and clinicians to mitigate high labor costs. Paying a nurses salary for a year with the sponsoring company’s emblem on his/her uniform might be the wave of the future. After all, we have endowed professorships in academia.
The internet of things (IoT) is the interconnection via the internet of physical devices, buildings, and other items — embedded with electronics, software, sensors, actuators, and network connectivity that enable these objects to collect and exchange data. It is also a hot topic in the healthcare industry today. For example, hospitals take advantage of the technology for real-time location services with badges that can track patients, staff, and medical devices along with asset management. Such assets include infusion pumps, wheelchairs, defibrillators, scales and other items that employees tend to tuck into out-of-sight corners yet are needed frequently for treating patients. In addition to real-time location services, IoT devices also help with environmental monitoring such as checking the temperatures of refrigerators or hand hygiene compliance. Sensors can also be deployed to track how often spaces are used.
Companies like Kaa have created an open-source IoT platform which allows original equipment manufacturers and healthcare system integrators to establish cross-device connectivity and implement smart features into medical devices and related software systems.
The following guidelines can be used to estimate the capacity and preliminary space need for a labor and delivery suite and associated antepartum and post-partum nursing units. The capacity will vary depending on whether the hospital is deploying the single-room maternity care concept exclusively — using combined labor, delivery, recovery, and postpartum rooms (LDRP rooms) — or if the mother and infant are moved to a separate postpartum unit after delivery.
I appreciate any comments that you have about the SpaceMed Newsletter.
— Cynthia Hayward