Does Your Facility Have Good Bones?
Increasingly, hospitals are searching for new and more efficient ways to deliver healthcare to their communities without sacrificing their high quality standards. The quest for shrinking operating margins causes hospitals to focus on simultaneously increasing volume while reducing operations (including staff), or go out of business. The evolution of healthcare facilities has forced healthcare planners to discriminate between “chameleons” (facilities that can evolve) and “dinosaurs” (facilities that will never evolve). To support new efficiency objectives, hospitals need to determine if their facilities are worth modifying toward this end or are in need of complete replacement.
In many cases, operational re-engineering has involved detailed review and evaluation of time and motion inefficiencies. The fact is, however, most successful hospitals have taken this step already and are now searching for the next evolutionary step in efficiency planning: a focus on the underlying physical facilities that may or may not support the time and motion objectives. A greater awareness of the “architecture of motion” (how physical surroundings and planning can enhance or inhibit efficient patient and staff flow) brings new insights to the evaluation of hospital systems, individual operations and, often, ways to achieve results through minimally invasive construction.
Healthcare campuses across the nation vary widely in how their physical facilities support efficiency. In many cases, a replacement facility is the only solution to solve the incredible inefficiencies of facility dinosaurs (figure 1). The response to this realization is often a massive capital investment coupled with significant cultural transition, both for the hospital and its community. However, the challenges—in terms of capital and culture—combined with communities advocating against relocation to new sites, cause many hospitals to redirect their focus from complete replacement back to more ad-hoc renovation or addition. This can be more acceptable from the first-cost standpoint, but its success depends on whether the facility has “good bones” to support these changes.
Characteristics of “dinosaur” facilities include ad hoc/reactive planning, poor wayfinding, the need for multiple entries, no center of gravity, and complex circulation patterns.
As healthcare architects, we see examples of facilities on a daily basis—both community hospitals and academic medical centers—that are clearly out-of-date dinosaurs that should evolve to extinction. On occasion, though, we see healthcare campuses that are, in fact, potential chameleons that may be able to successfully regenerate.
In evaluating whether a facility is a dinosaur or a potential chameleon, there are specific planning concepts that I have found to be essential to success, related in particular to the new architecture of motion.
Physical campus size, orientation, and location
The flexibility of the campus and its contiguous area should be evaluated to transition older hospital facilities into a new age of efficiency. Contiguous expansion space must be identified in terms of available land, selective demolition of older facilities, or both. The most valuable campus real estate may be defined within concentric rings radiating from the primary hospital elevator bank (the facility's functional center of gravity) to a limit of 300 feet for convenient access. Further assessment of the campus should include analysis of appropriate community and regional access. Ideally the campus itself will allow for independent access, with separate pathways for general hospital traffic, emergency traffic, and service traffic. There should be appropriate drop-offs with adjacent parking zones at these points of access (figure 2). One thing is for sure: Parking on the opposite side of campus from the main entry is a symptom of a dinosaur.
Characteristics of “chameleon” facilities include proactive planning, clear circulation and wayfinding, anticipated growth zones, an organizational center of gravity, and generic facility dimensions.
A subtle but critical aspect of healthcare planning is the clear organization of not only horizontal circulation, but also vertical circulation. The pathways need to be logical and efficient, with ease of wayfinding. Banking all elevators in a central location typically is more efficient than providing a series of elevator banks of one or two elevators each. A central point of vertical transportation may be considered the “center of gravity” for the entire institution, affecting the value of real estate on all levels adjacent to this point. Critical departments that are distant from this central point will be increasingly inefficient as distance increases.
The organization of clinical departments in support of an efficient care system often begins with a focus on the surgery department. It is useful for the surgery department to be three-dimensionally adjacent to PACU, ASU or daycare, central sterile, ICU, cath labs, emergency department, and diagnostic imaging, as well as the central elevator bank. If it meets many, if not all, of these adjacencies and shows good expansion potential for each, an institution likely will be demonstrating good bones for regeneration.
Soft planning versus hard planning
Clinical departments that are major utility and infrastructure users—not only surgery, but imaging, lab and the kitchen—are considered to be the “hard plan” departments within the hospital. Departmental adjacencies and circulation to and from these departments are critical. If these departments are colocated with adjacent functions such as administration, warehouse, clinic space, or doctor's offices, these “soft plan” departments are easier to relocate for the expansion of hard plan department needs. An existing layout including both soft and hard plan departmental adjacencies allows for better flexibility. Conversely, a facility that has its hard plan departments lumped together with no expansion potential is symptomatic of a dinosaur.
Older hospitals were rarely planned to have floor-to-floor heights of 13 to 15 feet. The infrastructure that supports today's facilities needs this “hidden” ceiling cavity, however, for renovation flexibility, access for maintenance, and reduced limitation on adjusting the layout. Ad-hoc development causing multiple floor level changes through ramps and half-story stairs reduces efficiency—a particularly challenging situation when it involves the primary diagnostic levels of the hospital.
Private versus public circulation
A central planning objective for any new facility is to clearly organize “front of the house” activities to be separate from “back of the house” activities. Public spaces and their interconnecting corridors should not be in contact with inpatient circulation, such as potential areas for stretcher holding or emergent or service access.
A consistent and generic structural bay repeated throughout the facility is an ideal framework for flexibility. Typical structural bay sizes of 28 to 36 feet are ideal. These dimensions are compatible with the size of state-of-the-art operating rooms, critical care rooms, and patient care rooms. Dimensions of structural bays that are less than 24 feet may have a negative impact on overall facility flexibility.
The most flexible structural frame for floor penetrations, as well as the potential for beam penetrations is steel construction. Although concrete frames may provide a shallower depth, concrete waffle slabs or pan slabs reduce flexibility of floor layouts and, therefore, renovation.
Utilities and infrastructure
As a result of the expense of upgrading or developing a new central utility plant, hospitals typically develop ad-hoc additions and renovations, with individual package units specifically designed only for the addition “du jour.” Along with the higher energy costs for a decentralized system, the maintenance required (and often neglected because of difficult access) is a significant challenge to the efficiency of facilities. A central energy plant with expansion potential is ideal.
The number of acute care facilities that are accredited through the U.S. Green Building Council's LEED program is relatively small. The recent initiation of the Green Guide for Health Care, now in its second edition, may assist facilities in achieving sustainability recognition. However, the final responsibility for planning green rests ultimately with institutions as they continue to evolve, project after project. If an institution has good bones, one of the basic premises of green planning—the most sustainable square foot is the one that is not built because this is, by definition, conservation of resources—is a starting point for this initiative.
Facility efficiency is not something that just happens—it needs to be planned, and a thorough assessment of available resources and assets is critical. The benefits of a “chameleon-like” facilities strategy can be most realized if it is well-conceived and integrated with the business plan; otherwise the resulting facility may become inefficient and in time evolve into a dinosaur. Strict guidelines for the use of vacated space or for important departmental adjacencies, as well as renovations and additions based on operational need and efficiency strategies, must take priority over internal political muscle by individual departments or physicians. A campus-wide facility master plan dovetailed with a strategic business plan is the ideal foundation for successful facility regeneration. This plan should anticipate five to ten years of growth and then project fifteen to twenty years beyond. The plan should also be updated every three to five years. Similar to an institutional strategic plan, the facility master plan should be understood and adopted by senior administration and kept current as a road map to the facility's successful future.
Of course the opportunity to replace an entire campus with up-to-date facilities should always be a serious consideration. If the capital is available, the return on investment is almost guaranteed in light of the possibilities a new facility offers, such as:
A potentially new operational culture
New traffic flow patterns and synergies
New focus around today's concepts in evidence-based design
Enhanced staff focus and possibly improved retention
New and efficient use of energy
Greater community/regional access and recognition
Economies related to flexibility
New identity or “branding” possibilities
Nevertheless, the potential of discovering a chameleon is worth the planning and assessment effort involved. With proactive leadership, innovation, and the presence of good bones, the evaluation may yield surprising and gratifying results. HD