Traditional rules of thumb in healthcare planning have changed. Skyrocketing land values, rising operational costs, new government regulations and standards of care, and intense competition have altered the healthcare landscape over the past decade. Once-accepted rules can now be the wrong course to take for healthcare institutions looking to maintain and grow their competitive position in the marketplace.

Whether in urban settings or on greenfield sites, sticker shock has made development costs for new facilities a major concern. Rising real estate values for in-town neighborhoods surrounding hospital campuses have made land acquisition more costly and have forced many institutions to look at rearranging existing facilities or at tearing down and rebuilding. Even in the countryside, where land is generally more plentiful, the ideal greenfield site is a vanishing commodity.

Facility operating costs also have gone through the roof, in part because healthcare environments have become more complex and need uninterruptible power sources and upgraded information system technology. Stricter government regulations and standards of care that are more reliant on sophisticated data and medical equipment have also forced the nonpersonnel costs of medical institution operations to rise. Finally, competition among hospitals in many states has spawned a whole generation of satellite and referral stand-alone clinics and specialty-focus facilities offering cancer care and orthopedic, ambulatory, women's health, and cardiac services.

In light of these societal, economic, and social changes, the rules of thumb that once dictated healthcare facility master planning must be examined carefully. Health facility planners, administrators, and CFOs may need to recalculate their pro formas or revisit their strategic thinking about future facility changes and expansions.

So, what are the new rules an institution should follow when undergoing a facility master planning exercise? A few salient ones to consider are presented in this article.

More Than One Patient Entrance

The rule of thumb mandating one entrance and lobby (and often an adjacent emergency department [ED]) is no longer valid. Each primary specialty needs its own entrance, image, and identity. Like the retail industry, which has moved from aisles of merchandise to numerous mini-boutiques within departments, hospitals are moving away from the image of a monolithic medical provider where all healthcare is under one roof. Hospitals are touting their specialties, boutique practices, and celebrity physicians, and the terms differentiation, repositioning, and branding have entered the healthcare provider's lexicon with a vengeance.

As a result, facility planning rules have changed. Technology and the interconnectivity of registration systems have made it easy. Planning entrances has become a discussion of “entrance zones,” with identification and branding being important considerations (figure 1). For example, the new cardiac and vascular care center at the St. Francis Hospital-Indianapolis campus required a separate entry for patient flow, but that separate entry also created an identity for relocated cardiac programs (figure 2).

Creeping Decentralization

Macrodecentralization (siting stand-alone ambulatory care and specialty facilities as satellites) emerged as a strong trend in the last decade, but microdecentralization within facilities is an emerging trend today.

Radiology is a good example. The old rule of thumb said to place radiology adjacent to the ED, but now separate radiology rooms are being increasingly located within the ED. For example, at Memorial Medical Center in Springfield, Illinois, a recent ED expansion included two dedicated radiographic rooms within the ED. A state-of-the-art computed tomography (CT) scan room is also included in this 30,000-square-foot department. Look for similar inroads into surgery and other units.

Point-of-care testing is the new paradigm in laboratory services, and rehab services are also making the move to point-of-care locations. In many hospitals and nursing rehab units, the inpatient physical, occupational, and speech therapy areas are located on the same floor and directly adjacent to the nursing unit and patient rooms. This approach has the dual benefit of reducing the distances inpatients must travel and involving the nurses more directly in the rehab process and treatment. The rule of thumb now is to bring these sorts of services, spaces, and equipment to the patient, not to roll the patient to the service.

The new Clarian Health Partners consolidated laboratory in Indianapolis is a large-scale example of this concept. Although lab samples are sent to the consolidated facility off-site, the patient is located in the laboratory for point-of-care testing. Scheduled to open in spring 2006, the consolidated lab serves three major medical institutions: Clarian Methodist Hospital, Riley Hospital for Children, and Indiana University Hospital-facilities that are located approximately three miles from each other. The facilities will use a pneumatic tube system located on the structural underside of a people mover (monorail) for delivering samples (figure 3).

Examples of an old entrance plan (above) and a new entrance plan featuring “entrance zones” (below).

The new cardiac and vascular care center at the St. Francis Hospital- Indianapolis campus.

Build New or Renovate?

Some rules of thumb need to be altered when deciding whether to renovate existing facilities or embark on new construction. In the past, hospitals usually went the cost-effective route of expanding departments into adjacent areas. Now it is believed that new construction is the best solution. In fact, new construction occurs in 50% of cases involving nursing units and primary outpatient and ancillary departments.

At Memorial Medical Center, a major ED expansion was required. During the planning and programming phase, it was determined that not all conceptual solutions drawn up for a renovation were practical or feasible. These solutions required that the existing entrances for ambulatory and ambulance-driven patients be closed and temporary entrances opened for long periods (figure 4). In addition, the extensive renovation of the ED would result in loss of revenue for an extended period. As a result of these findings, the solution was the construction of an entire new ED in a new addition (figure 5). This was the most cost-effective solution, based on patient, staff, and physician satisfaction; quality of care; departmental utilization; and duration of construction.

Higher land values and inefficient older buildings with poor layouts are causing many institutions to demolish buildings and construct replacement facilities with the latest in technology systems and consumer-focused amenities. Institutions are also building with more space than they need when possible, realizing that it is more cost-effective to build now and finish shell space once the demand or new services require it.

Even in rural areas, hospitals are acquiring more land than they need for projected facilities. Many have found that siting a hospital in a greenfield location attracts other healthcare-related development and, in some cases, becomes a market for various senior care facilities. By acquiring additional acreage, they are able to strategically sell off some “out lots” for economic gain and keep control over the quality and type of development that will surround them. Some new hospital facilities built on greenfield sites now opt to acquire 100-plus acres when they may only initially need 30 to 40 acres.

The monorail system linking campuses to the Clarian Health Partners consolidated laboratory in Indianapolis.

Conclusions

These rules of thumb will continue to evolve and change, and performance-based design principles will be used to measure for improved operational outcomes arising from facility upgrades. Not all rules will be relevant to every institution. Knowing which rules are important and which rules need changing is key to any hospital's ongoing facility planning. A facilities master planning exercise every four to five years will provide the information needed to move forward in changing these rules with confidence. HD

Gary Vance, AIA, ACHA, is a healthcare facility planner and Associate Principal, and Scott Radcliff is a planner with BSA LifeStructures, a national leader in designing healthcare, life sciences, and higher education facilities.