The specific needs being met by any given replacement project depend on the organization behind it, from accommodating growth in the patient population to introducing a new specialty program to simply meeting modern standards of care.

But it’s safe to say that no matter the goal, the way that new facility, unit, or department is operated will likely be different than it is in the one it’s replacing. So how do you ensure that what the project team has spent years planning, designing, and constructing is eventually used by staff in the way it was intended?

To fully prepare staff to treat patients in a new space, KLMK Group Inc. (Richmond, Va.) has created its “5 Rights of Operational Readiness,” which takes a facility through staff orientation, proper operating sequences, appropriate staff alignment, technology integration and implementation, and equipment education and implementation. Once those five objectives have been achieved, it’s time to open.

Healthcare Design spoke with Gary Wilkinson, principal and director of facility activation services, KLMK Group, to discuss the concept and shed light on how this approach will ensure that a project’s operational design intent is actually achieved.


Healthcare Design: You’ve said that on capital improvement projects, oftentimes operational planning comes as an afterthought. Why do you think that is?

Gary Wilkinson: There are multiple reasons I think that happens. Healthcare owners get so excited—you’ve got the construction team on site, the construction trailers, the designers. It’s easy to get caught up in the magnitude of the construction piece of it. Then you have end users who are consumed with picking out furniture and selecting their equipment.  You’re asking an entire organization not only to run their existing operations and maintain patient care and satisfaction, but you’re also asking them to do all these extra things. It’s easy to forget about the singular question: How are we going to operate in this new facility?


From your perspective, how do you define operational readiness and what should owners and the project team in general be thinking about?

How I define operational readiness is all the activities, all the planning, all the things you need to do so you’re ready to see a patient on day one. I’ve always phrased it this way with owners: I want nothing to be new the day that first patient comes through the door into your unit or into your department. Have you validated all of your workflows? Before you validate the workflows, have you identified the new workflows? What are your processes?

I’ll use this example: We had a project at a children’s hospital where we had an open NICU bay setting and a central nurses’ station. The new project called for a decentralized nurses’ station with private NICU rooms. It was a total change in the way they did business, provided patient care, and, really, it was a change culturally in how they’d been doing things for 10-15 years. We had to map out all the different steps we had to take so when we saw patients in that NICU department on day one, [staff] knew exactly where everything was and exactly how to do things.


How should project teams balance “operational readiness” with “facility readiness”? How are they similar and how do they differ?

The easy thing to talk about is facility readiness: What do we need to do to get that building open? What do we need to do to commission the proper systems in the building, to install all of the equipment, to calibrate to get the equipment up and running? What all do you need in terms of signage and wayfinding? Simply put—someone mentioned this to me a while back and it really makes sense—if you turned the building upside down, what all would fall out of it? That’s all the stuff we need to put into the building. That’s the facility readiness standpoint.

From an operational readiness standpoint, in that NICU example, you’ve got the facility ready and the nurse call [system] is installed; now when can we get the nursing unit on the floor to start training on that nurse call? When can the nursing unit get in the building to understand their new operational processes? Is it a new system? What bells and whistles on the system are new and how will that enable them to provide patient care?

Facility readiness really starts on day one [of the project]—it’s when you meet with the engineers and designers, and you’re getting that facility planned, designed, and constructed. I could argue that the operational readiness piece should start then, as well, in terms of what workflows and procedures are being developed as the design moves forward. Then the operational readiness piece is in a proactive planning state rather than a reactive planning state.


Where do the “5 Rights of Operational Readiness” come in? Can you break them down for us?

First, staff orientation, education, and training. Then, how does that play into the facility readiness coordination? Then the proper operating sequences are how a department is going to interact with other departments. For example, what does the operating sequence look like in your new facility from a patient presenting in the ED? How do they get admitted? What is their operating sequence to go from the ED, to imaging, then to surgery? What’s the process of getting them from surgery into a step-down unit? All those different things, the way we’ve got to map out their processes so, again, nothing is new on day one.

For appropriate staff alignment—I’ll go back to the NICU example—we had a 13-open-bay NICU department with staff who knew exactly what to do in that setting. When we went to the 24-private-room ICU, the staffing model changed. We have to understand the staffing model well in advance of certification of occupancy. We have to understand what the proper ratios are in terms of nursing staff and patients to make sure there’s no waste, that there’s no overstaffing, because those are real dollars. 

And technology is probably one of the things we run into the most in terms of the grandiose size of this topic. It is so ever-evolving. With that in mind, there’s always going to be the training from an IT perspective and a technology perspective of all types of systems within these new facilities. We’re also seeing a lot of these sophisticated healthcare facilities rolling out their new EMR projects.

So you have all sorts of new systems and applications that staff are not only trying to learn and understand what they do to help provide patient care, but then they’re also trying to learn and orientate themselves to a new department, along with a new staffing plan, staffing ratio, and new employees. So you have a whole lot of dynamics coming together.


What kind of training/orientation should be done to ensure staff is ready to use a new space as the design intended?

One thing we like to do is take a phased approach in terms of the orientation. We’ll do a building/life safety orientation to get everybody accustomed to where they’re going to park, what door they’re going to go into. It’s easy to assume that people know how to get into the building because I’ve been in it 20-30 times, but a lot of these third-shift nurses haven’t. So you have to be very detailed as to all the steps you need to take to get people into the building, where the egress points are, where the stairwells are, and then gradually come back and do your department-specific tours.

One thing we do is scavenger hunts, making this a depar
tment-specific activity where you can’t go to the next realm of training unless you know where the pneumatic tube is, know where the clean room is, and know where the medical dispensing stations are within the unit. And then start conducting your day-in-the-life scenarios. We’ve seen a lot of clients that will spend one whole day, 24 hours, and staff a department prior to go-live and run through different scenarios that we’ve been talking about in the planning phase.


To ensure intended operations don’t go by the wayside after the patient move, you recommend using a post-occupancy evaluation. What do you advise the POE cover?

That’s one thing that sometimes gets lost on a project. Toward the end, you’ve had a construction presence on your campus for years, you’ve really taxed your staff in that they had to maintain existing operations, maintain patient care, and maintain patient satisfaction along with trying to plan for the new facility. Once the patient move is over with, you sort of get to the point of “no more project; I’m done.” But what we’ve found is operational readiness really never stops. There are always ways to improve.

A post-occupancy evaluation helps us make sure what we planned for and prepared for, and what we designed and built, is being utilized in the way it was intended and designed for.

 For example, we had a project where we built 16 new ORs and the central theme around the design was to maximize throughput and efficiency to have more cases going in the surgery. The old way the facility had done things was get the case carts, put them in the surgery, and then leave them out in the hall. The new design allowed for a case cart storage center right next to the clean elevator that had a vertical transport element to go down to the central sterile department. The design, the program, and the process was such that we could get those case carts out of surgery, cleaned, and restocked in more of a fluid, turnkey operation. What we found was, yes, the design supported that notion, but the staff still wasn’t used to doing it that way. We found case carts in the hall. It really created a logjam because the staff wasn’t adhering to what we planned and prepared and, most specifically, trained for.

You can train and orientate all day long, but you will never be able to fully populate that patient floor to get an understanding of what it’s really going to be like until you go live. Then that goes back to the POE: Now that we’ve got a true setting of what our department’s going to be like, what’s wrong and how do we fix it?

Jennifer Kovacs Silvis is managing editor of Healthcare Design. She can be reached at