Based on “Planning for Tomorrow's Medical Enterprise: How Technology and Innovations in Care Delivery Will Redefine the Hospital”, presented by Catherine Maji, Vice-President, and William Woodson, Vice-President, Sg2, at HEALTHCARE DESIGN.06, November 7, 2006, in Chicago.

Planning facilities for tomorrow's healthcare is challenging. Newly built facilities are expected to last for decades, but care delivery is changing so rapidly and new facilities are expected to fix so many operational issues, that by the time new facilities are occupied they are often outdated. Rising construction costs mean design flaws are expensive to remedy. How can hospital executives, architects, and planners avoid costly mistakes and build flexible, cost-effective medical facilities?

New technologies, care protocols and processes, and even new types of specialists and caregivers, will radically change the healthcare landscape, making new demands on medical facilities (Table 1).

Table 1. Changing healthcare landscape: Examples

Examples

Key facility questions

Technologies

  • Nanoparticles will allow targeted delivery of contrast agents and drugs.

  • Mobile alert devices, smart beds, and mobile nurse call will improve nurse response time to patient falls and other emergencies by wirelessly sending alerts to context-aware surfaces and devices throughout the hospital.

  • Image-guided procedures and minimally invasive surgical approaches will continue to change the interventional landscape.

  • Telemedicine will redefi ne the four walls of a hospital, allowing physicians to guide treatment from remote locations and enabling improved care of stroke or trauma victims.

  • What are the facility requirements for adoption of the new technologies?

  • What should be built on campus? What should be built off campus?

  • What are our future bed needs?

  • How will the nursing staff provide care in the future?

  • How will the blur between surgery and interventional procedures change the facility layout?

  • What are our IT strategies? How will they change care delivery in the future?

Care processes

  • Multidisciplinary care continues to evolve. For example, a wide array of primary care and specialist providers—from neurosurgeons to home health professionals—will care for Alzheimer's patients, with care coordinated by an advocate or navigator.

  • Imaging and treatment will combine, allowing patients to be diagnosed and treated in the same offi ce visit for early-stage, contained tumors.

  • Smart technology and information system integration will allow for more robust patient monitoring and earlier detection of complications and errors, thus streamlining care delivery.

  • Does the facility plan (e.g., location and room size) foster multidisciplinary care?

  • How will the staff obtain information they need in real time?

  • Does the facility design optimize operational effi ciency and promote patient safety?

  • What level of fl exibility is necessary for our organization?

Caregivers

  • New specialists, such as molecular pathologist, super radiology technician, biomaterials specialist, cellular biologist, tissue engineer, and genetic pharmacologist, will be part of the medical workforce.

  • How will future specialists provide care in our organization?

  • Can the facility plan embrace future workforce changes?

  • How can the facility optimize the productivity of these new workers?

Demand for Healthcare Is Changing

Changing clinical technology and care delivery affect not only the processes and people involved in healthcare, but also healthcare utilization. At Sg2, we quantify these changes and many other impact factors in our Impact of Change (IoC) forecasting model. This model takes demographic changes—as well as technology, economic, sociocultural, payment, consumerism, and care-delivery factors—into account when predicting future inpatient and outpatient volumes.

Sg2's national 10-year IoC forecast for inpatient discharges (figure 1) shows what a difference these factors make. Based on population trends alone, inpatient discharges would be expected to increase 17% over the next 10 years. But when the impact of technology, care delivery, outpatient shift and other factors are considered, the overall predicted growth is only 10%.

Sg2 national forecast: Population growth overestimates demand (excludes neonates, normal newborns, obstetrics, and psychiatry). Sources: Impact of Change® v5.0 (IoC); the National Hospital Discharge Survey (NHDS); Sg2 Analysis, 2006

Figure 1 also includes projections for patient days and average length of stay (ALOS). Changing clinical technology and care delivery—for example, the adoption of minimally invasive surgery and interventional procedures—will bring about an 8% decrease in ALOS over the next 10 years. With discharges increasing 10% but ALOS declining 8%, patient days will rise by only 2%. This forecast implies the importance of operational efficiency to accommodate faster patient bed turnaround.

Outpatient services present tremendous growth opportunities over the next 10 years. The Sg2 forecast indicates that outpatient volumes will grow faster than population-based estimates would predict—17% over the next 10 years, as compared with the 10% growth indicated by demographic trends. The aging population, increasing survival of patients with chronic diseases, and patient expectations for continued activity at older ages are key drivers of outpatient growth.

Although the overall growth of outpatient volumes will be 17%, volumes of many specific outpatient procedures and services will grow at even faster rates (figure 2). To cite one example, PET/CT volumes will increase approximately 120%. The strong growth of the outpatient sector will require significant increases in outpatient facilities and resources. Organizations must get away from planning based on inpatient market share. Instead, outpatient services should be organized and managed as a business (or a portfolio of businesses) of its own.

Outpatient care presents growth opportunities. Sources: IoC; PharMetrics; Department of Health And Human Services' Agency For Healthcare Research And Quality's Healthcare Cost And Utilization Project (HCUP); the Centers for Medicare & Medicaid Services; Centers for Disease Control and Prevention; Sg2 Analysis, 2006

It's important to note that figures 1 and 2 are national forecasts intended to provide a general picture of future healthcare volumes. Of course, the outlook varies for different markets and different hospitals because of local factors, including demographic trends, case mix, and differences in technology-adoption appetites.

Faster Throughput Will Be Necessary

Merely predicting changes in demand is not enough to provide a complete picture of facility needs for the future. What types of patients will be using future medical facilities? The biggest growth area for hospital inpatients will be short-stay patients: those staying two days or less (figure 3). Discharges for this type of patient will increase 173% over the next 10 years, compared with only a 1% increase for patients staying four or more days. By 2016, patients with an ALOS less than three days will make up more than one-third of inpatient volumes. In planning new facilities, organizations must consider the growth of various patient populations and design new settings (that is, where the beds should be located), operational processes (such as lab results and imaging report turnaround), and even physician practice patterns (for instance, the timing of physician rounds) to handle brief admissions efficiently.

Short-stay patients account for the largest increase in discharges (*adult acute care discharges). Sources: IoC; NHDS; Sg2 Analysis, 2006

In fact, many organizations are realizing that different types of patients and different types of treatment require different types of facilities. It doesn't make sense to put relatively healthy patients who will be discharged in one or two days in the same facility with sicker patients with complex conditions who need longer hospitalization. Rather, patients will increasingly be segmented based on care needs. Better segmentation means better focus, and better focus improves efficiency and effectiveness.

Tomorrow's medical enterprise will segment patients into “focused-factory” disease-based centers and acute care centers (Table 2). Focused, disease-based centers, such as cancer centers and joint replacement/arthritis centers, offer patients convenient one-stop shopping and allow organizations to provide care efficiently in a lower-cost setting. Acute care centers treat sicker patients who need more complex, multidisciplinary care.

Table 2. Decentralized care

Focused disease-based centers

Acute care centers

Patient/case types

  • Outpatient and short-stay patients

  • Predictable/elective cases

  • Patients with:

    • ‐ Disease of unknown origin

    • ‐ Acute trauma

    • ‐ Infectious disease

    • ‐ Acute exacerbation of chronic disease

  • Complicated and/or unpredictable cases

Value proposition

  • Focused-factory concept for resource optimization and quick turnaround times

  • Continuum of care for a specifi c disease

  • Highly intensive resources for those who need them

  • Ability to perform complex procedures

  • Availability 24/7

  • Multidisciplinary teams

Success factors

  • Lower cost to build and operate

  • Lean manufacturing: zero wait time, consistent quality, repetitive processes

  • Rapid triage and diagnosis

  • Strategic adjacencies

  • Emerging technology adoption

  • Clinical excellence and patient safety

  • Real-time information fl ow

  • Management of end-of-life care

Care Will Be Decentralized

Construction costs are rising far faster than payment rates, and hospitals are competing with freestanding, physician-owned services with lower operating costs and more convenient locations than those of traditional hospitals. To meet these challenges and to take full advantage of patient segmentation, tomorrow's medical enterprises will comprise a portfolio of facilities that are conveniently located to provide services where the needs are (figure 4). Smaller facilities can achieve higher operational efficiency, compete more effectively with physician-owned services, and more easily accommodate care delivery changes and expansion. IT infrastructure is critical to providing connectivity among all the facilities.

Decentralized care is here now

Tomorrow's Acute Care Center

Streamlining care in the emergency department (ED), minimizing patient transport times through strategic adjacencies, and designing procedure rooms to accommodate emerging technologies are essential to building successful acute care centers for the future.

ED as a diagnostic center. Currently, 55% of hospital admissions come from the ED, which makes the ED the hospital's front door. Efficient diagnosis in the ED is critical to providing efficient and timely care. Technology such as molecular diagnostics and advanced imaging that produces results in minutes or hours instead of days will expedite triage. Emerging information technology will provide better communication and information access at strategically located access points.

Strategic adjacency. Clinical adjacency is another key to suc-cessful facility design. Inpatient imaging services, critical care, the ED, and procedure and operating rooms should be located near each other to minimize transport times and streamline care delivery. One organization that has achieved effective adjacencies is OhioHealth's Riverside Methodist Hospital of Columbus, Ohio, where the heart hospital is directly above the ED, a heated helipad is adjacent to the ED entrance, and diagnostic imaging is readily accessible to both the ED and the heart hospital (figure 5). This design, along with a wireless cardiac monitor and remote call system, allowed OhioHealth to reduce door-to-balloon time for angioplasty, a key measure of the quality of cardiac care, to less than 60 minutes (the desired standard is less than 90 minutes.)

Plan clinical adjacency to improve care. Courtesy of Riverside Methodist Hospital, Columbus, Ohio. (Architect: Karlsberger, Columbus, Ohio.)

Procedure centers. The increasing use of catheters, medical devices, and drugs has blurred the distinction between surgery and medicine. As the volumes and types of procedures continue to increase, providers must employ flexible facility designs that anticipate the need for large amounts of equipment and the presence of multidisciplinary care teams in procedure rooms. Operating rooms with a minimum of 650 square feet are becoming standard. Endovascular ORs, which can be used either as operating rooms or interventional suites depending on demand, will become common. Interventional ORs (also known as hybrid ORs) are being built in large centers to support emerging complicated interventional procedures. Next-generation picture archiving and communication systems (PACS) that distribute images throughout the hospital require careful planning for infrastructure and storage expansion. These items, although costly, are needed for the clinical pathways of the future.

Plan Tomorrow's Medical Enterprise

Changing technology and care delivery, rising construction costs, and increasing competition mean organizations must plan wisely to accommodate change and support the healthcare of the future. Organizations should:

  • Be prepared for changes in patients' needs and expectations.

  • Realize that the setup of today's hospitals cannot effectively lead to improvement in operational efficiency and quality of care.

  • Develop a strategic facility-planning process early on.

  • Assess the impact of emerging technologies and care delivery innovations on facility needs and design.

  • Determine facility needs based on future care delivery and changes in patient mix.

  • Integrate the facilities of tomorrow's hospital within an information-enabled environment.

  • Provide the right services in the right settings as a competitive strategy for the future. HD

Bill Woodson and Catherine Maji are Vice-Presidents and Dorothy Scott is Program Communications Director at Sg2, a forward-thinking healthcare research, consulting, and education company. Sg2 analyzes emerging clinical developments, technologic advancements, and market trends to help clients make informed business decisions, advance clinical excellence, streamline operations, grow market share, and exceed financial goals.

References

  1. Sg2 uses data from the following sources in its proprietary forecasting methodology:
  2. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov.
  3. Centers for Medicare & Medicaid Services. Available at http://www.cms.hhs.gov.
  4. Department of Health And Human Services' Agency For Healthcare Research And Quality's Healthcare Cost And Utilization Project. Available at: http://www.ahrq.gov/data/hcup/.
  5. National Hospital Discharge Survey. Available at: http://www.cdc.gov/nchs/about/major/hdasd/nhds.htm
  6. PharMetrics. Available at: http://www.pharmetrics.com.