As patient, industry, and regulatory demands heat up, hospital administrators are juggling increasingly urgent priorities. What role does the built environment play in meeting these de­mands? For the Healthcare Design feature article “Facility Owners Share Top Concerns In Serving Patients, Staff,” I interviewed executives from hospitals around the country. Richard Molseed, executive vice president of Avera Health in Sioux Falls, S.D., was particularly forthcoming with his system’s response to the current regulatory and patient care climate and the need to step things up for the future.  Some of his comments appear in the article linked above; what follows is the rest of our conversation.

How does Avera Health approach the addition or renovation of new facilities?
In our clinics, and in any new construction we do, we essentially Lean the process. We design or retrofit the physical environment to support the delivery method. It’s an integrated method, it's a very close-knit care team, and everyone is together.

We probably built the first clinic like that in 2008 or '09. And we made a ton of mistakes. We built a second clinic shortly after that, and fixed a bunch of [the mistakes], but still, we learned an awful lot. Now, we’ve actually been able to modify it.

So if you're a very busy family practice clinic, you'll get a certain design. If you're kind of moderately busy—maybe endocrinology, or something where it's not quite as many visits—you’ll get a different type of design. If you're, say, a neurosurgeon and you don't get a lot of visits every day, we're not as overly concerned about that. But in our areas that have a lot of patient demand (primary care, family practice, internal medicine, dermatology), we find that doing this front-end design work really pays off.

It creates this integrated approach to care delivery. When we do this, it builds this culture of high-quality care.  We’ve found that in our clinics, where we've been able to implement the Lean approach and evidence-based design, we get higher productivity out of our caregivers, higher physician satisfaction, and much higher patient satisfaction at the same time. We have everybody practicing at a much higher lever to their licensure, whether it's a physician, advanced practice professional, or an RN.  All that equates into, now, better quality scores. We don’t think of it in terms of cost control. We find that we spend a little more on allocating space, but our return more than pays for it.

In our older buildings, which we haven’t renovated, there isn’t necessarily any continuity of space or continuity of the equipment. And in our hospitals, we’re looking at a lot of renovation and thinking: What does that look like? We have a philosophy about the renovations, about what creates a comfortable environment for people under stress.

From an interiors perspective, it’s a classic feel. So we use, in public spaces, [faux] wood planking. In our initial waiting areas, we like to make them very family-oriented if we can. And our artwork is very definitive. We believe very much that our artwork has to work for us—as an example, in our inpatient hospice facility, near the nurses’ stations, we brought in a female artist in and asked her to create a piece that would help our people “escape.” So there's a picture of a nurse in her garden, and you're looking out from her home to her in the garden. And in her home is a book and a glass of wine, and it's a sunny day.  We know that artwork has a very special place with a lot of different aspects.

All together, these things need to drive everything you’re going to do. We’ve got to be efficient, we've got to get costs out of the system, the environment has to be supportive of our employees, and then the patients have got to be … if nothing else, they have to feel respected in the space. And as best as you can, you make the space enticing, and you enhance the experience.

What are some other big priorities for Avera Health today?
I see two big priorities: One is employee satisfaction. You know, I spend more of my conscious time in my office and building than I do at home. So we really take that pretty seriously. With our new construction, we try to make it pleasant, we try to involve our employees in design discussions, and we try to make it something that works for them on a day-to-day basis.

The other [priority] is point of pride. Are our employees proud of our buildings? Do they enhance the community we're in? Is it a point of pride for the community, that they can point to a modern or updated healthcare facility? In rural South Dakota, oftentimes, it’s a big deal in town—how well the hospital is doing. We’re starting to really take a look at that. There's a lot of demand in rural, in the plains area here, to upgrade facilities and clinics. And we know that when we've done that in the rural areas, we really do make a positive impression on the entire community.

How do you see your facilities evolving into the future?
We’re actually undertaking a system-wide evaluation of our facilities, which we've never done. We're trying to see how well positioned we are for the future. We're also trying to determine, in places that have an average daily census of less than one, what is the model of care delivery?

We’ve invested heavily in what we call Avera eCare:  We have our eICU, active eEmergency … if you're in this hospital that has an average daily census of 0.6, and you come in on an emergency basis from an accident or something, you literally push a button on a wall and within seconds, we have interactive video and data streams between that emergency department and a board-certified emergency care physician, an advanced practice professional, critical care nurses—and they’re all backed up by doctoral-level pharmacists and critical care physicians. That's how we have to deliver medicine going forward.

Our eHelm is a 17,000-square-foot space that’s 24/7, located away from our hospitals. It incorporates critical care, pharmacy, emergency, and primary care. And it's also our think tank for e-services into the future. So that's one thing we've given a lot of thought to, and has a space function to it.

How else does this kind of care delivery affect the built environment?
What is a hospital 10 years from now? It certainly isn't what it is today. I don’t know what it is, but I’ve got a feel for what I think it is. We’ve got a mindset around here that in 10 years, if you’re hospitalized—other than for things like childbirth, trauma, or surgery—it means the system has failed you in some way. Even surgery and surgery recovery is going to be less and less. So, what is a hospital?

That doesn’t mean there are fewer environments for care. But it's going to be in the home, it's going to be in the workplace, it's going to be retail shops, schools ... it's going to be in a lot of different places. It's going to be in front of your computer. So what is that designed environment?

Beyond that, I've got nurses at the bedside who are very much the kind of people who need personal contact. And now, all of a sudden, they're going to be nurses electronically? How does that translate, and what do you have to do with these people? How is it going to translate for those who aren't going to make that [transition]—it’s just not
in their DNA to do that?

So it’s not just a question of whether we’re prepared in a physical space, but also from an HR perspective, to deal with these transitions. It's very complicated. And it’s a fascinating topic. We all need to be asking these questions.


For more owners’ perspective on the evolution of the built environment, see (next page):