Strategic Planning and Institutional Health
Healthcare today is changing at an unprecedented pace as institutions around the country grapple with economic difficulties, divisive politics, and a population that is sicker than ever. Record numbers of aging patients suffer from debilitating chronic disease, and epidemics of obesity, cardiovascular disease, and diabetes plague a younger-than-ever population. Healthcare executives struggle with these challenges, trying to fulfill their corporate mission while watching their bottom line.
Strategic planning increasingly requires a roundtable approach to understand the impact of development over time. The “health” of an institution is measured by the effectiveness of its organization and mission, and also by how well it plans for the future. Three institutions that offer a unique perspective into what drives their decision-making processes are Bayhealth Medical Center, motivated by its deep community roots; St. Christopher’s Hospital for Children, focusing on maximum flexibility; and Geisinger Medical Center, striving to change the culture of healthcare itself.
Terry Murphy, president and CEO, Bayhealth Medical Center, Dover, Delaware
“Improving the health status of the communities we serve is the driving force behind our mission,” says Terry Murphy, president and CEO of Bayhealth Medical Center, adding that it’s also a touchstone for measuring the facility’s success. “We trend very well against peer institutions, though doing what’s right for our patients and their families is what drives our bottom line.
Bayhealth is the largest healthcare system in central and south Delaware, with a main campus in Dover, Delaware (Kent General Hospital), another in Milford, Delaware (Milford Memorial Hospital), and numerous satellite facilities. It also is a member of Planetree, an organization that promotes a patient-focused model of care, centered on a holistic approach to healing. According to Murphy, this is only one aspect of a successful strategy.
Like many hospitals, Bayhealth’s growth has been accompanied by the need to realign services and upgrade facilities. “We strive to make our facilities flexible enough to accommodate changes in program and technology,” Murphy says. “At our Kent campus, we had to acknowledge that we’d outgrown the original campus plan. We needed to develop a long-term approach to site circulation and expansion.”
“Repositioning materials handling and the central utility plant to the perimeter of the site immediately clarified patient and service flow and allowed efficient program infill,” says Andy Jarvis, director of healthcare planning for EwingCole architects and engineers, which advised Bayhealth.
In 2010, Delaware declared itself an “innovation zone,” challenging institutions throughout the state to collaborate on innovative approaches to keeping people healthy, reducing readmissions, and lowering the overall cost of care. Among many initiatives underway, Bayhealth is working with other organizations to implement best practices in the care of patients with congestive heart failure. This effort has led to discussions about how to improve or expand programs. “In determining how to place resources, we look at what the community can support,” Murphy says, “and where we would get the most synergies for staff.”
For example, Bayhealth currently provides cardiac surgical services only at its Kent campus, because the total volume of cases is at a proper scale to the experience of its surgical team. “We can’t at this point justify having two separate programs, given the demographic of the Milford community,” Murphy says. “The last thing we want to do is provide a service for the sake of having it; we want to invest in services that can be properly integrated and sustained by the size of the community, with high-quality outcomes.”
Bayhealth places “much of its long-term strategic thinking and resources toward keeping people out of the hospital. Focusing on health not only is better for patients, but also is more efficient and has a larger impact on overall cost of care,” Murphy says.
Patient education is a key component of the new preventive healthcare model, and Bayhealth offers free clinics, screenings, and ongoing health classes. “The emphasis on outreach has many implications from a facilities point of view,” Murphy continues. “We are looking at more opportunities to track our patients and improve their awareness. Within our new emergency department, for example, we’ve included smaller family waiting areas and information kiosks so that there are impromptu opportunities for health education. We also moved our medical resource library next to the main lobby instead of tucked away on an upper floor of the hospital.”
As important as the clinical departments are in determining the planning and organization of a hospital, getting to those departments and deciding what functions are placed along the way is just as critical. According to Jarvis, more clients are looking at facilities as a community crossroads, where the first floor is a complex juncture of arrival, wayfinding, and services. “This confluence of activities at the entry is often what helps to create a sense of place and an atmosphere of safety and reduced stress; a counterpoint to the clinical departments,” he says.
Maria Scenna, chief operating officer, St. Christopher’s Hospital for Children, Philadelphia
Like many established urban institutions, St. Christopher’s Hospital for Children, one of the premier pediatric hospitals on the East Coast, has experienced changes in clinical and practice trends. Maria Scenna, chief operating officer at St. Christopher’s, and other hospital executives face numerous decisions about how to spend their resources: transitioning to private patient rooms, advancing the neonatal intensive care unit model, or reorganizing clinics to operate more efficiently. St. Christopher’s also adapts to increasing patient demand. Emergency room visits are up—more than 66,000 visits a year—resulting in a recent 12-bay expansion to its 24-bay unit. While patient flow improved locally, there are still challenges ahead as the hospital balances the number of available open beds.
Acording to Scenna, “Kids in hospitals today are sicker than they were years ago. Our inpatient population is experiencing shorter lengths of stay but requires more critical care; we have a greater need for higher-acuity beds.” The hospital is moving toward a private patient room environment, where patients—and their families—have a home base. “This approach reduces inefficiencies and enhances patient safety,” says Natalie Miovski, healthcare planner at EwingCole, “since the level of care changes rather than the patient’s location. Reducing or eliminating transfers can result in significant reductions to average length of stay, frees up capacity, and even minimizes the need to fill open nursing positions. When step-down patients remain in their critical care areas, the same nurses can provide continuity of care, and everyone benefits.”
Like many hospitals, St. Christopher’s often has to decide between making infrastructure changes and purchasing expensive medical equipment. “As a premier institution, we need to upgrade our equipment based on the best technology that’s out there, which also enables us to attract consummate professionals,” Scenna continues. After a neurosurgeon was hired, the hospital purchased a neuro-drill for $90,000. Microscopes cost about $150,000 each, and ophthalmology microscopes can run $200,000. These are investments considered in the context of maintaining a highly specialized standard of care.
Ultimately, St. Christopher’s goal is to create the opti
mal healing environment for its patients. While the interior design of the hospital has huge visual and emotional impact, the actual cost represents a fraction of the total operating and construction budget. Planners and designers are challenged to integrate technology and get the most out of natural light, views, eco-friendly materials, low ambient noise, and comfortable furnishings that create soothing, uplifting spaces.
Dr. Alfred Casale, chief cardiothoracic surgeon and director of the Geisinger Heart Institute, Geisinger Health System, Danville, Pennsylvania
Geisinger Health System is nationally recognized for its innovative approaches to delivering high-quality medical care at below-average costs. The system includes a health insurance plan, which allows Geisinger to establish new medical protocols and to conduct extensive research on best practices, particularly in the prevention and management of chronic disease.
Geisinger consists of a main campus in Danville, Pennsylvania, and a network of clinics and hospitals serving more than 2.6 million residents throughout central and northeast Pennsylvania. In a 2009 speech, President Obama cited Geisinger as one of the nation’s three model healthcare institutions. Part of its success is its commitment to overhauling the healthcare paradigm.
According to Dr. Alfred Casale, chief cardiothoracic surgeon and director of the Geisinger Heart Institute, advancing patient education is one of the biggest long-term challenges we face. “As a nation, our expectation of medicine is that it’s there to fix you when something goes wrong; so it doesn’t matter what choices we make, as long as there is a drug or a cure for it,” he says.
This attitude shifts the emphasis to secondary prevention (a cure to a problem) rather than primary prevention (making healthy lifestyle a personal priority). One of the ways Geisinger helps to implement this shift is through its ProvenCare program, a version of the advanced medical home model. The health plan integrates care managers or “coaches” into the clinical team.
The manager, who is trained by primary care practitioners and specialists, keeps close track of the patients under his or her care. Every time the system “touches” the patient, it is reported to the manager, who calls the patient and coordinates appropriate care—for example, reminding the individual to pick up a prescription. “The patients get better care, experience fewer complications, and stay at home,” says Casale, who reported a 30% to 50% reduction in hospital readmissions after the program had been in effect for several years. The economics of this approach are just as promising as the health outcomes. “The health plan saves money, which it returns as a lower premium and by sharing some of the benefit with providers, in terms of fees,” according to Casale.
What is striking about the scale and integration of Geisinger’s strategic investment in health research and development of best practice tools is the implementation of its findings in the field. For example, Geisinger’s new nine-story, 320,000-square-foot Hospital for Advanced Medicine (HfAM), designed by EwingCole, features an acuity-adaptable planning concept.
According to Miovski, who worked with Casale on the planning of HfAM, “knowing that older versions of the universal room concept had not been successful, we were collectively challenged to understand what made the model fail and how it could be redesigned to succeed at Geisinger.” One solution was to leverage technology and integrate the acuity-adaptable room with an innovative eICU Program that enhances physicians’ ability to care for Geisinger’s sickest patients in the HfAM and other intensive care units at the main campus and ambulatory sites.
The eICU technology analyzes patient data from monitors, life support systems, electronic health records, medical orders, and other sources of information, and alerts staff when a patient is trending toward a serious health event. This eICU provides telemetry and “second eyes” that enable a quick electronic response from on-site intensivists and nurses via electronic communication.”
Another idea—promoted by nursing staff—was to use lightweight aluminum and glass hinged doors instead of typical ICU breakout doors. This allowed the team to create a beautiful inpatient setting with large windows while achieving the necessary access and visibility to the decentralized nursing areas.
Geisinger, Bayhealth Medical Center, St. Christopher’s Children’s Hospital, and thousands of other healthcare institutions across the nation, face new economic realities and continuing uncertainties. They also face opportunities to redefine their strategic vision and role in the new healthcare arena. Many have implemented an integrated planning approach that employs design and capital cost modeling earlier in the process. This expertise is invaluable in helping an organization reach consensus, establish priorities, and navigate change. HCD
Howard Skoke, AIA, is a principal of EwingCole, based in Philadelphia.