Every hospital goes through an-nual planning exercises to help it meet patients' needs most ef-fectively in the upcoming year. Is facility planning on your list? It should be, because facilities play such a vital role in the function of an organization. If your staff are footsore from running back and forth across a unit, your FTE counts just don't make sense, or your profitable service lines have nowhere to grow, it's time to focus on optimizing space.

With hospital construction cost ranging from $150 to 300 per square foot, there is significant initial investment that must be recouped over the life of the asset—your building project. Good planning optimizes space by thinking beyond the grand opening to the facility's operating costs. These costs include staffing, heating, cooling, life cycle of materials and finishes, and maintenance. Operating costs can be reduced by insightful planning and designing to make the most of the space.

Optimizing can occur in many ways: designing better storage on patient units to reduce nurse travel; using technology to get one more procedure per day out of the surgery suites; improving patient satisfaction scores with private rooms that invite family members to participate in care; or designing energy-saving systems. For your next project, here are some guidelines for optimizing space in your facility:

  1. Solidify operational plans. The first step in optimizing space has nothing to do with space at all. The foundation of optimization involves organization on a higher level. Ideally, hospital administrators and users should solidify operational plans before beginning a facility project. Operational models should be proposed, analyzed, and approved for the long haul on behalf of the hospital—not selected by one individual. This is especially important in nursing units and other staff-intensive areas of the hospital. The operational plan dictates everything from patient circulation, to quantity and placement of storage, to staff gathering areas.

    Operational changes can be difficult to discuss and implement, but their impact overarches how the hospital functions for years to come. The prospect of a new unit or facility can provide staff with the excitement and impetus to challenge “how we've always done it,” working together to examine best practices, incorporate new tools, and grow as a team—and in the process weathering the natural stressors of acclimating to a new environment.

    One hospital in the process of renovating its OB unit had determined that a labor, delivery, and recovery (LDR) concept made the most sense for its patients and staff. When nursing leadership changed, the preference became a labor, delivery, recovery, and postpartum (LDRP) model. This caused a significant pause and cost increase in the project until the LDRP model was tested to determine its merits. The lesson? Don't let one individual dictate a change that affects the project in a profound way—staffing changes are too common to let one person design the unit.

    Architects can offer valuable suggestions about operational changes simply through observing work flow in the space. The design can focus on alleviating some of the issues, including circulation bottlenecks, “homeless” equipment, and patient safety. If an operational change does take place in the midst of a project, be sure to tell the architect as soon as possible, to prevent the continuation of a design that will never fit or function the way you envisioned it.

  2. Build in patient safety. Patients are in the hospital to get better. While medical care does carry some risk, it can be minimized through design. For example, the less often patients are transferred, the less likely they will be victims of misidentification, leading to medication or treatment errors.

    Standardization has been proven in many industries to help prevent people from making errors, and that principle holds true for healthcare facilities. Identical universal rooms—usually sized and equipped to accept a patient of any acuity—beyond being the same size, locate all equipment, casework, and supplies in the same place, no matter which room or which patient (figure 1). Busy staff in crisis situations can quickly access the right tool. (Note: For hospitals that are concerned about first cost and may be in a state of change caused by demographic or market factors, it sometimes makes sense to design rooms large enough for any type of intensive care patient, but forgo the more elaborate headwalls needed for critical care. As the need for critical care rooms grows, these large-sized rooms can be retrofitted for critical care.)

    Universal patient room: Universal patient rooms provide flexibility that supports patient acuity and maximizes the use of each room

    Account for computers in designing for staff processes. Caregivers benefit from bedside charting both because of the immediacy of the record keeping and because it eliminates the need to travel to separate computer and desk areas. If bedside charting isn't in the budget, locating nurses' computer stations between rooms is a way to save travel and preserve continuity of care (figure 2).

    Pediatric intensive care unit: Modular nurses' work areas and computer stations located outside pairs of patient rooms allow staff to easily and efficiently document patient progress and reduce “back and forth” travel

  3. Be kind to your staff. Nurses and other care providers have physically demanding jobs and aging bodies, just like the rest of us. Reducing travel time and backtracking, facilitating visual access to patients, and placing equipment and devices conveniently within reach without requiring bending and stretching all pay off with reduced injuries, leaving your staff with that extra bit of energy to get through the shift.

  4. Minimize specialty spaces. This is especially important for small hospitals that maintain specialty areas with low and widely fluctuating censuses. For example, many rural hospitals maintain an ICU in a separate wing or floor. An average daily census hovering around 1.5 still dictates the need for a dedicated nurse and ancillary support. Universal rooms, as described earlier, allow patients of varying acuity to be comingled on a unit, maximizing staff productivity.

  5. Defeat underutilization by keeping exam, diagnostic, and treatment rooms busy. The notion of setting aside specialty clinic rooms for practitioners who are only available three days a week is outmoded and grossly inefficient. A standard room—typically equipped with a sink, a computer (or writing surface), an exam table, family space, and often a portable cart carrying the relevant supplies—can be used by two specialists on alternate days, generating cash flow by being used five days a week. The room, sized large enough to accommodate various practitioners, stays the same; only the contents change.

    Are rooms being used appropriately, or could activities be moved to better serve both patients and staff? In a recent expansion of an imaging department, the architect recognized that long wait times were leading to fewer patients being seen. Analysis revealed a simple cause and solution: Patients were using the procedure rooms for changing. Establishing separate, nearby, private changing areas for men and women allowed imaging rooms to be turned over faster, benefiting patients with shorter wait times and the hospital with greater productivity.

    Even nontreatment spaces can be better utilized. As part of good citizenship and public relations, many hospitals will offer their conference space, including lecture halls, to health-related community groups for education and support activities. While the payback may not amount to revenue, it's an effective way to help community members familiarize themselves with the facility and to foster goodwill.

  6. Conduct behind-the-scenes planning to prepare for the future. Structural design sets the stage for the next renovation and expansion. To keep options as flexible as possible, an open grid design with minimal fixed columns will allow corridors, rooms, and walls to be more easily moved to accommodate changes.

  7. Be green. Sustainable features have merit in healthcare facilities, beginning with the philosophical match between caring for patients and the environment. The more practical aspects include energy savings and an improved patient care environment. Designing as much access to natural light as possible is a logical first step, especially in public areas. Light streaming through windows in healthcare facilities provides a crucial connection to the outdoors and reduces dependence on electrical lighting (typically 20 to 25% of a facility's total energy consumption) (figure 3). Photosensors further minimize the need for electric lights and maximize the impact of daylight, allowing electric lights to “fill in” as necessary to reach desired lighting levels throughout the day.

Waiting area: Green-tinted, super-low-e glass, a daylight harvesting system with electronic sensors, and an aluminum light shelf/sunscreen integral with the curtain wall combine to take advantage of natural light. This saves energy and warms and brightens the waiting area

Additional strategies for maximizing energy dollars include occupancy sensors for offices and meeting rooms, water sensors to limit the flow of water from sinks, LED lighting for exit signs, and an energy-management system that tracks excess loads so that they can be corrected in a timely fashion.

As healthcare continues to reinvent itself in response to economic, regulatory, and social pressures, facilities must contribute to the efficiency of the organization rather than draining resources, encumbering staff, or irritating patients and visitors. Use the ideas offered here to generate discussion when you begin to contemplate facility improvements. With a knowledgeable healthcare architect as your planning partner, your next building project will meet numerous goals—from aesthetics to maximally optimized space. HD

Thomas M. Grove, AIA, is a healthcare principal at Flad & Associates, Madison, Wisconsin. As a project manager and medical planner, he has been instrumental in dozens of successful hospital renovations and reorganizations.

For further information, phone (608) 232-1325 or e-mail tom_grove@flad.com. Flad & Associates is a national planning and design firm with five offices in the United States. Specializing in technologically complex environments, Flad serves the healthcare, biomedical and pharmaceutical research, and academic communities. To comment on this article, please send e-mail to grove1103@hcdmagazine.com.

Healthcare Design 2003 November;3(4):28-30