Critical Access Hospitals (CAHs) provide essential medical services to rural communities that otherwise would have little or no access to care. They’re part of a special class of Medicare hospital that, according to a 1997 law, must be at least 35 miles from any other hospital (or 15 miles in mountainous terrain), have 25 or fewer beds, offer a maximum stay of 96 hours, and have a 24-hour emergency room.

Without the program’s cost-based reimbursements, many of these hospitals wouldn’t be able to sustain operations. They’re simply too remote, and their populations too small, to function with standard Medicaid and Medicare reimbursements. They don’t benefit from the economies of scale that their urban counterparts do, their patient counts are lower, and their operational costs are higher by proportion.

To make matters worse, recent changes in healthcare have hit CAHs hard, creating pressure to reduce inpatient stays and drive patients toward less costly (and less profitable) outpatient care. The decision by 23 states not to expand Medicaid under the Affordable Care Act has strained the budgets of small hospitals in those states.

Furthermore, with the 2013 recommendation by the Office of the Inspector General that program requirements for CAHs be tightened, the designation that helps ensure the survival of these hospitals is under threat. Some experts now predict that 20 percent of these hospitals will close by the year 2020.

Because of these tough economic realities, it’s crucial that CAHs improve their efficiency and find better ways to serve their communities. Now more than ever, the financial health of CAHs and the health of the populations they serve depend on facility design that maximizes operational efficiency and reins in costs.

Maximizing staff efficiency with smart adjacencies
Payroll typically accounts for 50 percent or more of hospital budgets, so efficient use of staff time is a critical component of a CAH’s finances. Efficiency can be improved through designs that create smart adjacencies and shared nurses’ stations, which allow nurses to oversee multiple departments during less busy times.

“One reason we designed our new facility the way we did is to optimize staffing,” says Julie Slagle, head of nursing at Sidney Regional Medical Center in Sidney, Neb.

Sidney is a town of 7,000 in the Nebraska panhandle, about three hours from Denver. A 25-bed replacement hospital is currently under construction there, the design of which will greatly increase efficiency and quality of care.

“The facility we’re in now is older and over the years has had a lot of departments added onto it. What ends up happening is, it becomes a lot of long hallways, a lot of walking space, and a lot of inefficiencies,” Slagle says.

“Let’s say I’m a nurse. A patient is being admitted, and I need to take him for an X-ray, labs, and then to his room. Right now, I’m going to have to walk down two hallways to get to admissions, get the patient, take the elevator down a floor, walk down the hallway to the lab, then back to the elevator, go up, and then walk directly back to the area above the lab, which is radiology, for an X-ray. Then it’s another 150 feet down a hallway to his room.”

The new design for Sidney places the nurses’ station at a critical node in the hospital’s circulation, giving nurses quick access to the inpatient, emergency, surgery, lab, pharmacy, radiology, and labor and delivery departments. “Everything’s right there,” Slagle says.

This increased efficiency is allowing Sidney to grow. “We’re actually not cutting [full-time equivalents]. At the same time that we’re building this facility for efficiencies, we’re also building staff,” she says. “As our services grow, our utilization of services grows.”

In the next year, Sidney will add two physicians, two physician assistants, and a full-time surgeon.

And because of how the design anticipates growth, any future expansions to Sidney will be completed without adding more hallways.

Making maintenance self-sufficient
Facility maintenance in rural areas can be challenging, too, especially when something breaks and qualified repair technicians are hours away. “We work around those limitations to select equipment that the staff is comfortable with maintaining. It’s best to include mechanical equipment they can maintain themselves,” says Kim Cowman, mechanical project engineer with Leo A Daly.

When designing the mechanical system at York General Health Care Services, a 25-bed CAH about an hour west of Lincoln, Neb., Cowman specified an air-cooled system to replace the aging water-cooled system, thus eliminating pumps and control complexity.

Backup generators for CAHs require extra design attention because in cases of emergency, rural areas are often the last to be helped. In several instances, Cowman has recommended larger-than-code-minimum fuel tanks. The key question guiding this decision: “How soon can a tanker truck get to your facility if there’s a large storm?”

In York, despite relative proximity to Lincoln, the answer to that question was up to 96 hours. A 4,000-gallon diesel tank was installed, which is quadruple the size that code requires. In fact, it’s closer to what military installations use, says Doug Nelsen, electrical project engineer at Leo A Daly.

“It came down to how remote the area was and not having a guarantee of fuel service being provided within that time should a large weather event or power outage occur,” he adds.

Similarly, a history of brownouts in Fairfax, Mo., with a population of 638, led engineers to specify a high-wattage generator for Community Hospital Fairfax, a 16-bed CAH.

When selecting a boiler for Sidney Regional, Cowman specified redundant boilers that allow flexibility of fuel sources. For example, a high-efficiency boiler running on natural gas provides energy savings during normal periods, and a backup, standard-efficiency boiler that can run on either natural gas or fuel oil provides heat in an emergency.

As for control systems, Cowman says planners of CAHs should consider installing one with remote Web access. “If something goes wrong and the town is too isolated for a qualified tech to be there in person, support staff can access the system through a secure Web-based portal and diagnose the problem remotely, instead of troubleshooting over the phone with the facilities staff.”

Catering to outpatients
As care shifts from inpatient to outpatient settings, CAH design is changing to improve outpatient access and efficiency.

“More hospitals are using a front-door approach to planning radiology, lab, and pharmacy placement,” says Jonathan Fliege, senior architect with Leo A Daly. “Before, radiology might have been buried inside a hospital, but now we design them with storefront access to the public space. That way, your expenditure for a radiology room can easily be used for outpatients.”

CAHs are also increasing operational efficiency by sharing some facilities with clinics. In both Sidney and Fairfax, support spaces, dock services, environmental services, and laundry are shared with adjoined clinics, decreasing square-footage, up-front costs, and operational costs.

More cost savings are achieved by designing a clear and distinct break between hospital and clinical facilities.

“Hospitals are designed to an incredibly high safety standard, so every square foot of hospital costs much more than a square foot o
f clinic,” says Fliege. “If you think about an emergency in a rural community, like the tornado in Joplin, Mo., the town needs to congregate at the hospital for safety and medical care. The hospital needs to be designed to ‘institutional’ code, but by placing a fire wall between the clinical and hospital sides, the clinic side can be designed to less expensive ‘business’ standards.”

With an increased emphasis on preventive care, many CAHs also are being designed to include a wellness component. In Sidney and Fairfax, the public sides of the buildings feature meeting rooms that can be used by the community to hold health education classes.

Improving the patient experience
Although federal mandates tying Medicare and Medicaid reimbursement to outcomes and patient satisfaction scores do not apply to CAHs, rural hospital administrators place a high value on improving the patient experience, something that’s good for business and community relations.

“In building our new wings, our goal was improved patient experience and safety—privacy, quietness, and reducing falls,” says Jenny Obermeier, head of nursing at York General Health Care Services.

For example, she’s seen a distinct drop in the number of patient falls thanks to updated and expanded patient rooms that provide clear paths to the bathroom and less clutter. Additionally, the rooms provide more natural light and family space, two things Obermeier says also contribute to patient satisfaction.

Adaptation is critical
In the face of today’s healthcare challenges, the survival of CAHs, and the health of the communities they serve, requires designers and hospital administrators to rethink entrenched design methodologies and operational procedures.

In some cases, that means remodeling facilities to maximize use of staff resources and redesigning to meet the challenges of a changing healthcare market. Despite all the threats facing CAHs, good design can help the strong survive.


John W. Andrews, AIA, NCARB, is a vice president, senior project manager, and healthcare practice leader at international architecture, engineering, planning, and interior design firm Leo A Daly. He can be reached at Jeff S. Monzu, AIA, NCARB, is a vice president and senior project manager at Leo A Daly. He can be reached at