With all sorts of uncertainties constantly revolving around the healthcare sphere—be it economics, healthcare reform, or changing models of reimbursement and care—how can healthcare providers optimally plan for the unknown?

As a starting point, experts advise providers to focus on known factors in order to develop a viable strategy moving forward.

Consider this: Healthcare costs are escalating faster than inflation and income, the health insurance system is shifting from fee for service to fee for performance, and IT demands are on the rise. Ultimately, an organization’s evolving patient care structure and supporting facilities infrastructure should reflect this.

For example, with out-of-pocket healthcare expenses increasing and the average household income remaining flat, this means that more consumers are postponing healthcare treatment.

“If this trend continues, patients reaching the doors of healthcare providers will have significantly more acute conditions than what is witnessed today,” explains Debajyoti Pati, PhD, executive director, Center for Advanced Design Research & Evaluation, and professor at Texas Tech University, Lubbock, Texas. As such, healthcare providers need to “move as much of the care as possible away from the high-cost acute care setting to make it affordable for the general populace, and that means more construction dollars will need to be spent on non-acute care facilities.”

Meanwhile, the evolving fee-for-performance model is driving an unprecedented number of mergers, consolidations, and realignments, as healthcare networks work to reposition themselves to be in the “right locations for the right reasons,” explains James G. Easter Jr., FAAMA, SVP, principal and director of planning, HFR Design, Brentwood, Tenn.

In line with Pati, Easter also foresees healthcare entities moving away from traditional acute care settings to service delivery systems, which he describes as access points away from the main hospital campus, reaching farther into the community for greater access and convenience. He cites Duke University Health System’s partnership with Lifepoint Hospitals as one example. Their agreement is aimed at combining the tertiary level of care with community acute care, in addition to moving from the medical center campus into outlying regions of North Carolina and Virginia.

In a similar vein, Zachary Hafner, associate partner, Oliver Wyman, Chicago, says that “over the coming years, we expect to see significant value migration—from inpatient facilities to patient-centered care models; from transactional care in silos to horizontally integrated and coordinated care; and from repair to prevention and early intervention.”

Dedicated dollars
Of course, healthcare institutions are inevitably working with limited funding, so capital expenditures must be prioritized. In some cases, the most profitable departments like surgery, cardiology, orthopedics, women’s health, and neuroscience will be the first to receive construction dollars.

On a more micro level, Dennis L. Kaiser, AIA, LEED, principal, Perkins+Will, Boston, says, “Without question, new IT systems and automation are high on the ROI value thinking. Beyond this, planning concepts that allow for flexibility, such as universal or modular room dimensions, and that envision the future use as well as immediate need of a space will provide payback across the life of a facility investment.” 

Meanwhile, Simon Bruce, RIBA, Assoc. AIA, EDAC, vice president, SmithGroupJJR, San Francisco, advises focusing on areas subject to the greatest change, such as surgery, imaging, pharmacy, lab, and emergency. In addition, variables such as the building’s age, code compliance issues, program and space demand, budget limitations, and strategic business initiatives to increase competitiveness should also be factored into the equation.

Advocating a very thorough approach, Easter believes that it’s short-sighted to give revenue-generating services precedence over areas like service support, maintenance, and office/education. Instead, Easter frequently takes his clients through a comprehensive master plan analysis where departments and programs are evaluated on a case-by-case basis.

“As we study each service area for size, environmental condition, functionality, and process mapping/flow/efficiency, we redefine what seems to be working and what isn’t working. The analysis addresses the existing space, the workloads and volumes, the flow, the environmental character, and the location,” he says.

The next step is to organize the dozens of departments that have been analyzed into a master zone/re-zone where these services might be located in the future, and how they might be improved over the next three to 10 years.

Flexibility first
Naturally, flexibility is a major priority in any healthcare planning endeavor, and can be defined via adaptability, convertibility, and expandability, according to Pati.

For example, “Selecting structural systems that allow for ease of conversion and/or expansion—horizontal or vertical—are essential for providing future flexibility and the ability to adapt as healthcare models evolve,” says John H. Thomsen, PhD, PE, SECB, principal, Simpson Gumpertz & Heger, Boston.

While steel-braced frames or concrete shear walls for lateral load-resisting systems may be more attractive from a first-cost standpoint, Thomsen cautions that in the long term, these types of systems usually limit future adaptability.

In terms of overall planning, Bruce suggests the following strategies to maximize flexibility and ultimately achieve more value with less investment: 

• Applying the concept of “loose fit,” which is designing extra space into a room and/or department to allow for easy adjustments in the future;
• Designing universal rooms within defined categories of use;
• Continuing integration of IT via communication networks, emergency medical records, picture archiving, communication systems, bar coding and radio frequency identification, and intelligent and personalized wayfinding systems;
• Optimizing rooms for multiple intended functions with appropriate equipment and supplies always available for a scheduled event; and
• Integrating automation and robotics to improve efficiencies and boost workflows. 

Adding to this list, Kaiser sees building information modeling and modular construction as valuable tools to enable cost-effective healthcare construction. For example, “large sections of duct work may be formed in the shop and delivered to the site to simply lift into place, and repetitive rooms such as bathrooms may be built on an assembly line,” he says.

Plan priorities
In the broad scheme of things, one major way healthcare institutions are planning for the future is with the aid of a well-developed and thought-out master facilities plan.

“A master plan provides and documents the logic and intentions behind a long-term growth plan. Not having one—especially in the current climate—represents suicide for any provider organization,” Pati says.

Therefore, after donning such a long-term lens, healthcare systems must ask themselves how they plan
to respond to the public need for urban design, parking, operational efficiencies, eventual full replacement projects, and new models of care and growth.

Offering some general guidance, Mark Tiscornia, MBA, LEED AP BD+C, associate vice president/healthcare principal, HGA Architects and Engineers, San Francisco, explains, “A set of guidelines and an overall vision can be more effective than a prescriptive plan that’s overly detailed. Exact future needs can’t always be predicted, so the best approach is to establish a loose framework that a variety of future needs can flexibly fit into.”

Bruce suggests, “The master plan needs to be conceived more like a road map with multiple possible destinations and multiple routes of travel. The forces of change can be external—such as healthcare reform or competition from other providers—or from internal forces, such as the acquisition of a new specialty physician group or the purchase of new technology. This new model of master planning is about nimbleness, integration, and flexibility.”

Adding some key points, Easter advises that the master plan process include the following: 

• Re-visit the plan every three to five years to build upon past knowledge, but with trend adjustments linked to strategic service delivery and business plans;
• Respond to market/service delivery needs based on new governmental and IRS dictates, to define area need in all public hospital settings;
• Address third-party payer expectations and accountable care measures anticipated for the future; and
• Link to the annual capital budget, which takes into account how much each department needs to stay effective, staffing, and how equipment fits into existing or new space. 

Yet another useful strategy for long-term planning is developing and utilizing universal building standards. In fact, Tiscornia explains that such standards can improve consistency, regulatory compliance, operational efficiency, branding, patient experience, and clinical safety. As a purchasing tool, standards can lower costs by increasing the quantity of material ordered from a single vendor, and as a design tool, they can shorten the design schedule and reduce costs.

Pati also sees universal building standards as a way to ensure faster capital construction projects. However, he recommends that they only be used as a starting point to a solution within a specific context, as treating the standard as the universal solution could backfire.

Similarly, Easter cautions that modular and standardized layouts should be handled carefully to help prevent the “rubber stamping” of design products by irresponsible parties. “A modular or prototype service doesn’t fit all locations, and it’s important to creatively adapt modular buildings and components with very experienced A/E teams who understand the value of innovative and creative design. One size does not fit all,” he says.

Crystal ball
Though change is inevitable, Bruce says, “We also have trends in behavior triggered and reinforced by a variety of factors.” He’s identified the following as some of the most significant trends and issues that will need to be addressed: 

• Demographics, i.e., the graying of America;
• Insurance reform changing fee for outcome to fee for service;
• Value-added improvements in operational quality and performance;
• Operational cost reductions including increased utilization and efficiency, and improved patient safety and reduced medical errors;
• Healthcare reform;
• IT integration;
• Increased use of automation and robotic technology;
• Advancing clinical technology; and
• Evolving models of care and delivery. 

Emphasizing the urgency of planning for the future, Kaiser says, “Unfortunately, the healthcare institutions that have not come to grips with the understanding that significant change must be pursued are the institutions that will not be around in the future.” 

Barbara Horwitz-Bennett can be reached at bbennett@bezeqint.net.