Four takes on planning
Before the first meaningful design concept hits the drawing board, project planners and programmers set the rules of the game. How will the facility be organized? What are the goals, and how are they to be prioritized? How will designers obtain information, and from whom? Who will make which decisions? What sort of communication will be expected of all parties involved? Answers to questions such as these guide the architectural drawings and, ultimately, provide meaning to the groundbreaking and construction. And it comes probably as a surprise to no one that, in healthcare design, these answers have been changing and, increasingly, defining a new game.
Recently, HEALTHCARE DESIGN asked four prominent participants in the healthcare planning process to address these questions: How does today's planning process differ from the traditional one? What seem to be some of the principal goals of today's planning process? How does an effective planning process deal with multidisciplinary participation? What is the best approach to take in allowing for technologic change? Does the modern planning process come into conflict with traditional hierarchical/political hospital structures and, if so, how can this be resolved? Their answers have been assembled as the mini-essays that follow.
David F. Chambers, Director of Planning, Architecture & Design, Facility Planning and Development, Sutter Health, Sacramento, California: It is essential to understand that in an ideal world, facility planning would not be done separate from strategic, clinical, and technologic planning. The underlying goal of all healthcare facility plans is to enable the care organization to balance its capacities with its community's healthcare needs and maintain sustainable operations. Perhaps a higher goal would be to facilitate a breakthrough in improving the model of care through architecture. But this is not possible through traditional planning; nor is it possible when facility planning is isolated from other key planning processes or outputs.
The traditional facility planning model is downstream from strategic planning and applies little focus to the clinical model beyond the bed environment itself (if even that). “Process” is generally not discussed, other than perhaps developing a matrix of proximity relationships between departments without challenging their boundaries, leaving clinical planning with no alternative than to propagate significant process gaps.
Six Sigma–type process improvements, when and if applied, identify incremental improvements to fragmented processes rather than organizational breakthroughs. (The question that needs to be asked here is: “Isn't a 3% improvement of a broken process still a broken process?”) As a result, plans perpetuate the departmental structures they evaluate.
To develop a plan that can successfully move an organization toward achieving real breakthroughs in operational efficiency, patient safety, and optimized outcomes, the planner must create “intersections” between clinicians, administrators, and support staff. Each group tends to see the world through its own context without associating with the other. By putting representatives of many related services together and visualizing the current state of operations, and then visualizing how we might work if the walls didn't get in our way, we have been able to envision powerful, consensus-based process optimizations that transcend departmental barriers. For example, by reassessing cycle times in optimized processes, we are balancing our capacities with strategic initiatives in a much more meaningful way. (Does the organization really need two more operating rooms, or does it need to enhance throughput to more effectively use the ones it has?)
A medium-size acute care medical facility can actually be planned with as few as three multidisciplinary groups.
Optimization strategies generally begin with combining like processes (such as prep for surgeries, prep for endoscopies, and prep for catheterization procedures), minimizing queues, balancing cycle times with capacities derived from strategic initiatives, and then planning the overall facility response. The resulting planning concepts are comprehensive service centers oriented toward a philosophy of “one stop, one wait,” and they require significantly fewer staffing resources than do the traditionally separated departmental configurations.
Key facility features of these plans include Patient Intake Centers that consolidate many of the admissions processes and pretesting processes into a single stop, Invasive Services Hubs that provide a single receiving center for all patients requiring prep or step-down recovery, and Acuity-Flexible Patient Rooms configured to minimize patient transport.
These concepts can ultimately evolve to challenge the traditional divisions between acute and nonacute care, and into envisioning entirely new facility configuration concepts. Recently, we began evaluating much deeper integration of physicians with the acute care service with which they interface. This has led to a concept we are calling IBIX: Integrated “B” and “I” occupancies configured as an X (as per Ron Marshall, Sutter Health Vice-President of Systems Development).
Generally, this facility concept connects physician specialties into fully integrated floor plates within their acute care facilities. These plates rise above an ancillary base that provides for a range of dedicated, technologically sophisticated, centralized diagnostic and treatment spaces. Patient circulation and service access are dramatically simplified, with few “centers” to access. The floors are configured radially, allowing contiguous growth along each of the four legs (the X) and bridged by the acute care facilities across two legs of the X (figure).
The IBIX concept. *D&T = discharge and transfer.
Because code requires different fire, life-safety, and physical environmental criteria for different occupancies, I-1.1 in the figure is the occupancy associated with acute care facilities (and is the most stringent of the three); B occupancies typically accommodate physicians' offices but could certainly house administrative support, a significant percentage of clinical support, and even much of the diagnostics; and I-1.2 occupancy includes outpatient surgeries which, like B, have somewhat less stringent building construction requirements compared with those of I-1.1. Typically, B and I-1.2 occupancies require less substantial construction materials and methods, less complex structural systems, and lower-energy-consuming environmental systems.
IBIX simply takes advantage of these lesser requirements by housing occupancies in the construction actually required to house them. This results in decreased building and operational costs and expedited building programs. The resulting savings in first-cost and building energy consumption can exceed 20%. The ultimate driving goal of the IBIX concept is to consolidate clinical programs into comprehensive services, thereby eliminating much of the wasteful duplication so prominent in healthcare departmental operations today.
One might imagine so great a change in the way our programs work that the facilities themselves are virtually “free” in light of the operational improvements they allow. Capital costs tend to amount to 6 to 10% of today's acute care operation, while staffing equates to 50%. If by consolidating programs, eliminating queues, and combining like services we can improve operational costs by 15%, facility costs would be negligible.
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Bill Rostenberg, FAIA, FACHA, Principal, Anshen+Allen, Architects, San Francisco: The process for healthcare facility planning is evolving along with changes in healthcare delivery. Delivery of health services today is characterized by a growing interest in reducing medical errors, leveraging the capabilities of scarce staff, and transforming potentially disruptive medical technologies into collaborative technologies that disarm territorial boundaries rather than enforce them. As a result, healthcare facility planning and programming today are often more collaborative and less departmentally focused than in the past. For example, opportunities for sharing expensive diagnostic and treatment equipment, space, and staff are preferred to solutions calling for redundant duplication of such assets.
Such collaborative, multidisciplinary planning requires endorsement and buy-in from everyone—from top administration to the end users. However, solutions to physical design and operational issues cannot be established without first addressing political issues of territoriality and internal competition among specialists.
Today's design goals include accommodating a desire to have multiple options, flexibility, convertibility, sustainability, and an image that describes the high quality of services provided within.
In planning for the long term, it is best to accommodate systemic change rather than specific detailed change, which is more difficult to predict. For example, relatively minor investments up front in extra infrastructure capacity (e.g., air handling, power supply, space, etc.) will allow a measure of change to occur without necessitating comprehensive facility redesign.
Gary Lahey, Managing Principal, Sterling Planning Alliance, Boston: It is essential to have the planning process managed through an executive management group. Although the process works only with involvement of people at the service director level, because these are the people who are probably most in touch with their fields, executive managers need to challenge their individual visions for their departments in terms of care practices, technologies, and reasonableness of their assumptions. The executive manager should attempt to tie these visions into one that encompasses the entire institution.
Multidisciplinary involvement is essential, and “blue skying” is important, but eventually all this has to be translated into facility requirements. Someone at the executive management level has to integrate departmental views with a global view and set ground rules and boundaries for the discussion. In short, having all this as a directed process is the key. And this takes leadership.
One way we try to assist people at all levels in the planning process is to match them up with people in relevant areas who have planning experience and can give advice in that area. Learning from someone who has already gone down all the blind alleys can provide a tremendous shortcut for contemporary planners.
For example, we recruited the developer of an integrated cancer care program in New England to help a New Jersey health system develop its own such program. Also, a regional health system in the United Kingdom hired people from a healthcare system in Boston to improve its throughput for cancer care. The health system learned that improving the effectiveness of its diagnostics was the key; the American consultants were able to pinpoint periods of underutilization caused by scheduling and other administrative practices. It really had nothing to do with technology—although the consultants and their clients did eventually move into areas such as picture archiving (PAC) and other technologic innovations, including voice recognition, which helped speed up the diagnostic screening process.
In planning for technologic change in itself, planners need to be aggressive in their sizing of units and design them modularly, so that the same rooms can be used for different purposes, as needed (an increasingly common practice). They must take care to provide a flexible utility zone to allow for expansion of infrastructure.
As an architect in a previous life, I became more involved in operations when I began to understand how much facility planning is driven by operational considerations, such as costs and clinical practices. I found it helpful to be working higher in the planning food chain, where we could have more real impact.
Frank J. Sardone, President and CEO, Bronson Healthcare Group, Kalamazoo, Michigan: Today's healthcare planning process is an ongoing one, with research on best practices in hospital design done well in advance of drawing up blueprints. Healthcare is changing more rapidly than ever before, so studying the trends in patient care and technology to get a sense of what is to come ten or more years from now is critical. Planning today also should involve visiting other facility sites and researching at home—such as focus groups with current patients, employees, and physicians—to make sure that planning is abreast of what patients and staff need, want, and expect.
Principal goals of today's planning process are that the project be:
Patient-centered. The design must help foster quality outcomes as well as excellent service delivery.
Flexibly structured, with efficiencies that support staff productivity
Dedicated to using evidence-based design
To achieve the best results, facility planning must be done with input from all key stakeholders. A multidisciplinary steering group should be formed that has mutually agreed-upon assignments for each division (nursing, physicians, facilities, communications, operations, etc.), with individuals held accountable for accomplishing each assignment according to an established timeline. With a formal process such as this for both planning and operationalizing a move into a new facility, one can avoid common pitfalls, such as not meeting deadlines or an individual not knowing he/she was responsible for completing a particular action.
To best allow for technologic change, one must research what is predicted to occur over the next ten years and gauge where the organization will be in terms of technology adoption. Also, consider whether the organization tends to be an early or late adopter. Then plan the facility accordingly, but build into that design as much flexibility as possible. The flexibility to move walls and reshape spaces, for example, is important in order to maintain adjacencies and efficiencies, versus having to move a service to a less convenient location to accommodate changes in technology.
Although it is conceivable that the modern planning process might come into conflict with traditional hospital structures, if the facility planning process is integrated into the hospital's ongoing strategic planning process (which should also include technology planning), conflict can be avoided. It is optimal to look at facility planning as a continuing process that senior management oversees in the same way they do operations, rather than something to be done by a special committee every decade or so. HD