During the recent challenging economic period and current era of healthcare reform, U.S. health systems and hospitals have shown limited appetite for large-scale acute care facility development as they reposition their organizations.

Consequently, many healthcare design firms looking to maintain their revenue base during this period have rapidly expanded their international reach to offset reduced domestic activity.

This change has brought new challenges for healthcare planners and designers as they’ve had to gain an understanding of diverse global practice patterns, new cultures, and different sets of operational criteria and healthcare delivery methods in a relatively short period of time.

International projects are typically large-scale efforts with complex programs, limited fees, and demanding schedules that require senior medical planning staff to expeditiously move a project forward during a period when the entire project planning and design team is trying to understand the goals and objectives of a new client.

This is further complicated when a client approaches project development differently or may not have a clear understanding of future desired concepts of operation.

International project business plans largely focus on defining the number of inpatient beds, inpatient procedures, and associated outpatient physician practice clinic visits since they’re the primary basis for revenue projections.

The high degree of focus on inpatient care with an employed physician practice model is very different from our traditional domestic outpatient-centric delivery model and creates challenges for medical planners to understand the intended scope of the project as predesign efforts begin.

Familiar benchmarks and anticipated interrelationships of volumes and operational assumptions aren’t applicable internationally and, therefore, finding your footing can be difficult. Inpatient admission rates and length of stay by subspecialty vary greatly by geographic region, and by public and private institutions.

While we would expect a younger median age population in geographic regions such as the Middle East to require less acute care beds than the aging U.S. market, that’s not usually the case. The high percentage of minimally invasive outpatient surgery in the U.S. drives lower inpatient admission rates compared to international models of care delivery that have not adopted as high a level of outpatient surgery.  

Also, the lack of a mature health insurance market in many countries with national public healthcare systems means that patients are paying out of pocket for care in private hospitals and have different expectations. Many would feel slighted if a facility didn’t offer at least an overnight stay after surgery, even for basic ophthalmology cases, which drives up admission rates.

International practice patterns

Inpatient length of stay can also be impacted by a lack of post-acute care options for patients to recover outside of the acute care setting.

In the U.S., we have a host of alternative care models, including long-term acute care facilities for ventilator dependent patients, acute medical rehabilitation centers for post-surgery and stroke patient recovery, and skilled nursing, long-term care, hospice, and home health programs designed to expedite discharge from facilities.

Internationally, the focus has been on acute care facility development without consideration for post-care facility benefits. The lack of alternatives delays discharge and adds to the bed demand requirements.

Other practice patterns further impacting length of stay include pre-surgical testing occurring after admission and an overall lack of timely diagnostic testing. Together, these issues can add 1 to 2 days to an average domestic patient length of stay.

When it comes to business plans, many clients present limited assumptions defining primary centers of excellence with minimal supporting information for the majority of remaining clinical services.

At times, they define a general number of beds without a breakdown by subspecialty, requiring detailed service line discussions to understand expectations and desired bed complement by service line. During these discussions, medical planners have to help fill in the blanks regarding overall facility needs to support the anticipated vision for the medical center.

Once a general understanding of beds by service line has been established, additional operational planning studies are required to understand the interrelationships between beds, procedure rooms, ancillary clinical service diagnostic rooms, and outpatient clinic physician practice exam rooms by subspecialty.

This information is then used to project detailed room demand requirements and complete the functional space programs prior to beginning schematic design.  

Understanding operational benchmarks

Operational benchmarks can also vary overseas. For example, scheduled hours of operation and encounter duration for ancillary clinical services and physician clinic visits vary widely, affecting the planning criteria and throughput benchmarks.

Most CFOs in the U.S. can only dream that a physician would see 48-plus patients in an 8-hour day in a single clinic exam room, while many, if not most, international practitioners do this to compensate for limited reimbursement per visit.

International use rates for ancillary clinical service testing is also much less, which reduces key room demand and space requirements. Conversely, limited regional reference lab and other contract services routinely available in the U.S. do not exist in many areas.

Therefore, highly specialized laboratory services are routine in most international facilities. For example, cyclotrons can be common where nuclear medicine and PET services are offered due to lack of contract services and availability of diagnostic isotopes on a regional basis.

Determining facility needs

A lack of just-in-time delivery services and degree of available contract services means international medical support and logistical program requirements are also quite different.

Full-scale laundries and large materials supply storage facilities are the norm. Dietary perishable food and dry goods storage can also increase depending upon regional distribution networks.

Maintenance facilities can be impacted depending upon the degree of work performed on-site.  All of these issues must be considered as the preliminary project scope is being established.

Overall, as healthcare firms continue to expand their practices globally, medical planners need to gain a detailed understanding of clinical practice patterns and concepts of operation outside of the U.S.

With tight project delivery schedules, and even tighter fees, medical planners are under pressure to complete predesign planning activities quickly to move the project forward expeditiously.

For those involved in international projects, it’s an exciting time with many opportunities to learn different approaches to delivering care and to expand our knowledge base.

Raymond E. Brower

Raymond E. Brower is vice president at RTKL Associates Inc. (Washington, D.C.) and can be reached at rbrower@rtkl.com.

For more on international design, check out:

Part One: Designing Abroad: How Sustainability Is Making An Impact In The Middle East

Part three: Designing Abroad: Cultural Considerations In Evidence-Based Design