Over the past several years, healthcare reform and economic conditions have caused many healthcare institutions to delay or reduce already-limited capital spending on architectural projects, focusing instead on operational or technological change within existing buildings.

This has translated to necessary projects becoming long overdue. As providers begin to correct the situation, architects and designers are positioned to play a key role in the process, particularly in helping to create new or renovated spaces that are more operationally efficient.

This need for efficiency is surfacing thanks to healthcare reform changing the economics of healthcare—transitioning from a fee-for-service model to outcome-based reimbursements. Accountable care or team-based care is an approach many institutions are taking to manage population outcomes and costs. This model is intended to reduce overall expenditures while at the same time more comprehensively answering patients’ needs, a holistic approach to care that relies greatly on staff collaboration.

At the same time, the number of insured and older patients is growing quickly as baby boomers move into their mid-60s, with an increasing shortage in caregivers and technicians helping to create a perfect storm for health economics. According to the National Center for Health Workforce Analysis, the gap in caregivers is projected to be in the range of 800,000 by 2020, requiring current caregivers to be more flexible, efficient, and cross trained.

Staffing pressures are influencing the recent inclusion of family as part of the caregiving team, taking on basic tasks nurses traditionally perform. Meanwhile, rapidly evolving technology is changing how procedures are performed, records are kept, and people communicate.

Healthcare architecture must continue to evolve to contribute to the new efficiency required of today’s care delivery models. The latest health facilities of the past can no longer be the model for the future. Two key areas ripe for improved design include procedure space and inpatient beds.

Consolidating interventional services
Technological advancements in surgery, cardiac catheterization, and interventional radiology offer the potential to explore the physical consolidation of shared support services. Typically these departments are located in separate areas of a hospital or campus, each with their own prep/recovery space, staff and support space (lockers and lounges), and patient services (reception, scheduling consultation, and even purchasing).

Traditionally, extensive building corridors connect these areas across large distances. Because interventional services all require patient sedation, anesthesiology physicians and staff are required in all locations, as well, despite the distance. This translates to significant travel or staff duplication—and a lot of wasted time walking.

Additionally, interventional radiology and cardiac catheterization/electrophysiology procedures, while minimally invasive, will require increased sterility levels similar to the surgery department, per changing regulations to minimize risk of infections.

Finally, each group staffs its own recovery area, which at times may lead to overstaffing. For example, at end of day, occupancy of a recovery area is reduced because checkouts aren’t replaced with new patients. Rather than have each interventional area maintain staffing even though some areas are no longer full, consolidating services could allow staffing to be reduced.

A consolidated interventional department is a new conceptual approach to eliminating these types of redundancies; providing a better facility response through modularity and room flexibility; and encouraging greater collaboration, cross-coverage, efficiency, and support for these services.

A modular procedure room, for example, can be developed to provide a facility with plug-and-play room utilization over time. One single pre/post-anesthesia care unit can effectively respond to the daily ebbs and flows of patients and be more efficient for the end-of-day reductions in space and staff needs.

On the front end, patients and families have one destination, a more spacious waiting experience, centralized tracking information, and a convenient consultation area with physicians. The support side of the concept includes a single staff lounge, collaboration space, one set of lockers, centralized communications, and a singular point of transport services.

The approach reduces overall program space, offers a more streamlined operation, and enhances the patient and family experience through simplified wayfinding and reduced confusion.

New concepts for prep and recovery areas, including space for family members, shouldn’t conflict with the clearances needed for equipment and staff functions. The inclusion of family at the bedside may, therefore, add a few extra square feet to a patient room, but their presence provides support to staff during the recovery period, while reducing patient stress and speeding recovery.

Clustering beds
On the inpatient side, a traditional hospital “racetrack” layout strings rooms down long corridors, increasing walking distances, reducing visibility into patient rooms, and contributing to an institutional experience.

Inpatient clinical staff often spends a significant amount of time hunting and gathering supplies and medications, changing over soiled rooms, and checking in to charting areas centralized on the floor. Clustering patient rooms around decentralized staff work areas can reduce this time spent walking from room to room.

For example, North Shore Medical Center in Salem, Mass., relocated its ICU to a larger floor and expanded from 16 to 20 beds. The center of the floor organizes circulation and support spaces as objects in a large field. Program elements are laid out as colorful cubes, organized to maximize visibility across the floor. The only enclosed rooms are two utility rooms and a housekeeping closet.

Though 20 beds is not a large floor, concern over travel distance resulted in the provision of a clean supply, soiled utility, linen supply, medication alcove, and nourishment alcove for every 10 beds.

At Swedish American Hospital in Rockford, Ill., a new cardiovascular building is based on the idea of grouping patient rooms into eight-bed clusters that maximize staff visibility to patients while minimizing the distance between rooms. Compared to a typical linear or racetrack room arrangement, the clustered rooms reduce walking distance between eight rooms to 55 feet from more than 100 feet.

Additional support spaces are close by and shared between sets of two clusters, maintaining efficiency of materials management and restocking supply. Further, four staff stations for 32 beds allow younger staff to be associated with more experienced staff to foster mentoring.

At Nemours Children’s Hospital in Orlando, Fla., a 27-bed inpatient floor is organized into three pods of nine rooms that all have computer charting and basic supplies in the room. Because staff will be assigned to a pod, travel across the entire floor isn’t necessary, and each pod has a dedicated pneumatic tube station; nourishment station; and work, supply, equipment, clean, soiled, and quiet work rooms.

By minimizing distances to support areas, staff is able to spend more time on direct patient care in the rooms.

For patients and families, the often overwhelming scale of a bed floor is reduced, and each pod has a more intimate feel. Each pod neighborhood is accessed from a primary corridor, meaning that visitors to a room at the end of the floor don’t need to pass dozens of patien
t rooms along the path of travel, bringing a higher sense of privacy to patients.

Family on the care team
The days of limited visitor access and visiting hours are coming to an end, as family members and loved ones are spending more time with patients in the patient room. Family is becoming a member of the care team that assists patients with food, toileting, ambulating, and other aspects of the healing process.

To accommodate families, patient rooms often include amenities, such as sleeping areas for overnight stays, desks for working, movable tables for in-room dining, refrigerators, and increased storage.

At Nemours Children’s Hospital, an integrated seat at the window has removable bolsters that create a comfortable sofa by day and a sleeping surface by night. A mobile desk provides a workspace for parents or a coloring space for siblings, and can be arranged in the room to serve as a small dining table for family dinners.

Summing it up
A 2006 American Hospital Association study provided a breakdown of costs for an average healthcare development over a 10-year period, showing 8 percent of costs dedicated to initial construction, 4 percent to equipment and non-construction, 8 percent to utility and energy costs over the 10 years, and 80 percent related to staffing and operations. This breakdown of costs remains the same.

Therefore, if designers are able to value engineer operational and staffing needs by 10 percent, the design can absorb the cost of construction.

This opportunity to address the finances of healthcare construction projects can be realized with a conscious focus on operational efficiencies that shave dollars and improve the patient and family experience.
 

Dennis Kaiser, AIA, LEED AP, is principal at Perkins+Will in Boston. He can be reached at Dennis.Kaiser@perkinswill.com.