Renovations and new construction are adding value to patient care by building in operational efficiencies, increasing patient convenience and creating opportunities for clinical collaboration.
As hospitals and health systems prepare to move from a fee-for-service to a value-based model, executives and board members are confronting hard questions about what it means to be a hospital in an increasingly ambulatory world. In response, they are shifting their focus to managing population health and delivering more integrated care. And they realize these efforts won’t be successful unless they are supported by a physical environment that enables efficient management of community health needs.
“Our clients are telling us that they are interested in exploring a wide range of strategies for bringing more value to patients while reducing costs,” says Will McConnell, vice president and regional practice leader, health care, in the Chicago office of design, architecture, engineering and planning firm HOK.
Most organizations are striving to deliver better care at less expense, and remodels and new construction are opportunities to make significant progress on those fronts. For example, grouping outpatient diagnostic testing into a single facility makes routine procedures more convenient for patients who have long been forced to go to multiple locations.
Similarly, thoughtful design and construction can help to offset shrinking reimbursement. Building in operational efficiencies can accelerate patient flow and increase providers’ capacity, while sustainable materials and structures reduce energy and maintenance spending.
These points were underscored by respondents to Health Facilities Management magazine’s 2014 Health Facility Design Survey. In fact, enhancing operational efficiencies was the No. 1 factor driving changes to facilities design, as cited by 91 percent of the 582 health care architects, facilities and construction professionals who responded to the survey.
Advocate Health Care, Downers Grove, Ill.; MaineGeneral Health, Augusta; and the MetroHealth System, Cleveland, are among the organizations that have embarked on design and construction projects to meet the evolving needs of patients and providers. These projects illustrate how leaders are addressing the new health care environment by creating new environments of care.
Modernizing for Convenience
According to Michele Baker Richardson, chair of the board of directors of Advocate Health Care, the transition from a fee-for-service structure to population health management has led the system to focus increasingly on chronic and post-acute care, with investments in outpatient care and physician networks. “Advocate has been changing its model of care for a number of years to better meet the needs of patients, which, in many cases, means keeping them out of the hospital,” she says.
Richardson adds that those patients who are hospitalized require more acute levels of care; for this reason, Advocate is modernizing a number of its campuses to strengthen intensive care and provide amenities like private patient rooms.
The modernization project at Advocate Good Shepherd Hospital, Barrington, Ill., involves the construction of two major additions and the renovation of more than 30 percent of existing hospital space. The project broke ground in 2012 and is targeted for completion in 2017.
The design reflects the latest approaches to both inpatient and outpatient care. On the inpatient side, new intensive care space and medical-surgical beds will allow the hospital to provide private rooms for all acute care patients. It will have a universal care unit for patients who need surgery, cardiac catheterization and interventional radiology services; combining these services in an integrated interventional platform will streamline clinical operations and reduce the amount of support space required. For outpatients, the hospital is building an integrated testing center to serve as a one-stop shop for most diagnostic and testing services, so patients will not have to travel to several locations for routine medical tests. A chronic care clinic will consolidate services for patients with chronic conditions like diabetes.
The integrated service components were developed via a Lean process planning effort led by HOK, in coordination with Advocate performance improvement staff, McConnell says. This effort was based on reducing unnecessary steps, bringing value to the patient and optimizing both care and operational processes. “All of these principles are targeted at the value-based purchasing objectives that are at the center of the new, post-ACA world,” he says.
Lean thinking also is demonstrated by the hospital’s project delivery model. Advocate opted to use an integrated Lean project delivery team, consisting of the owner, architect and contractor, and tapped HOK and Minneapolis-based Mortenson Construction early in the process. By working cooperatively, the design and construction professionals have been able to lower costs, improve quality and benefit the overall project schedule a number of ways, McConnell says. For example, involving trade partners early in the design process gave the electrical contractor the opportunity to perform a detailed review that determined that the project required one fewer emergency generator than initially specified.
The project’s design and materials play a role in increasing value and reducing costs in patient care. For example, the team is using Advocate’s facility systems standards, such as standard room layouts and finishes, which are designed to support a consistent level of care across multiple facilities and allow for economies of scale in purchasing items like prefabricated bathroom pods and headwalls. The building floor plan places high-volume services, like the integrated test center and rehabilitation, close to the main entrance for patient convenience, in line with the retail health services trend. Infrastructure for updated technology, including a real-time locating system for patient tracking, is being installed to improve workflow and reduce the likelihood of clinical errors.
The facility is being designed and built in accordance with the U.S. Green Building Council’s LEED certification program and the Healthier Hospitals Initiative. Sustainable design features increase operational efficiency through energy-saving measures, and promote community health.
David Nelson, chair of the Advocate Good Shepherd Hospital governing council, says the council and hospital leaders used community health assessments and focus groups to understand local residents’ needs. He says the governing council has presented the project at numerous community meetings and receives bimonthly progress reports from hospital leadership. “Expansion and colocation of outpatient services provide greater patient convenience, better coordination of health services and more streamlined care for the patient,” Nelson says. “We are honored to be making the vision a reality for our community.”
Consolidating Services Drives Collaboration
MaineGeneral Health recently completed two major design and construction projects to consolidate inpatient and outpatient services. Previously, the organization had three hospital campuses. The system closed two campuses and replaced one with a newly designed and built facility, the Alfond Center for Health, Augusta, which opened in 2013. MaineGeneral renovated a second inpatient building to create a comprehensive outpatient care center, the Thayer Center for Health in Waterville. Renovations to this center were completed last year.
The Alfond Center for Health inpatient building features 192 private patient rooms for behavioral health, critical care, general med-surg, rehabilitation and women’s health services. Private preoperative and recovery rooms are provided for patients served by the hospital’s interventional platform, which includes operating suites, a cardiac catheterization laboratory and procedure rooms. Comprehensive diagnostic services are located adjacent to the emergency department.
The Thayer Center for Health — the largest outpatient facility in the state, according to MaineGeneral — has an ED; physician offices and clinics, including dialysis, rehabilitation and speech therapy; radiology and same-day surgery departments; and centers for pediatric care, community health/prevention, conferences and education, among other services.
Stephanie Calkins, M.D., MaineGeneral’s incoming board chair, sees the value in developing clinical models that work collaboratively and physically close together. “Being able to look at [inpatient and outpatient services] as a bigger whole, rather than several pieces or silos of care — that, I think, is going to be important,” she says. She notes that the accountable care organization model requires a thorough understanding of a health system’s comprehensive service plan and patient population. “That’s harder to do if you’ve got multiple facilities, multiple service lines [and] multiple campuses spread out,” she says.
Consolidating services in one outpatient center and one inpatient center in the service region “brings people together,” says Calkins, giving caregivers more opportunities for face-to-face interaction and setting the stage for population health management.
The facility plan already has boosted the health system’s ability to recruit and retain medical specialists by providing a strong primary care and referral base. Part of MaineGeneral’s strategic plan is to provide services to all patients close to home, so the availability of specialty care consultations is making a “tremendous difference,” she says.
Initially, community members had reservations about the broad scope of the Alfond and Thayer projects, but several community forums gave residents an opportunity to learn more about the projects and provide input. The success of MaineGeneral’s Alfond Center for Cancer Care, a newly constructed consolidated cancer center also located in Augusta, helped to demonstrate the benefits of integrated care to the community.
Calkins says the board, led by a strong finance committee made up of experienced, committed financial professionals from the community, is taking a multiyear approach to funding the Alfond and Thayer projects. She notes that MaineGeneral was in good financial standing going into the project and budgeted an initial two-year loss. This is expected to be mitigated by long-term savings; the sustainably designed facilities are expected to cost $7 million less to operate than the older buildings they replaced.
Integrated project delivery and Lean construction methods made the design and construction process more efficient. To create the Alfond Center for Health, MaineGeneral partnered with general contractor joint venture partners Robins & Morton, Birmingham, Ala., and H.P. Cummings, Winthrop, Maine, and architecture firms SMRT, based in Portland, Maine, and TRO Jung|Brannen, Boston. In a statement, Robins & Morton reports that the collaborative project was finished 10 months ahead of the original schedule, saving MaineGeneral about $1 million in financing costs for each of those months. Plus, the integrated project delivery team calculates that it returned $20 million to the health system in value additions and other design and construction efficiencies, such as increased square footage for the data center and the added dialysis unit.
Calkins says that throughout the project, the board received monthly updates from the design and construction team. “Everybody got to know [MaineGeneral COO] Paul Stein,” she laughs. “He loved talking about it. His excitement was very infectious.”
Overall, she says, the project “went wonderfully — beyond what we could have imagined.”
Reinvigorating a Neighborhood
MetroHealth is in the initial stages of an ambitious plan to redesign and rebuild its entire medical campus.
The health system has served its community in the Cleveland neighborhood of West 25th St. for 175 years. “The main campus is driving the whole process, because our buildings on the main campus are old,” says Tom McDonald, MetroHealth System’s board chair. “I think 70 percent of them have outlived their useful lives, so we have to do something. But at the same time, we need to be more efficient, because of the Affordable Care Act.”
Designing new facilities to be more efficient and more welcoming to patients and their families will go beyond transforming the campus, says McDonald. “It’s the transformation, really, of the way we’re going to deliver health care moving forward.”
MetroHealth is conducting an extensive outreach program related to the project, inviting local residents to participate in the planning process. “We’re constantly soliciting feedback from groups and individuals,” McDonald says. The health system is holding community meetings on campus and in the neighborhood, running a social media campaign and operating a website that outlines the vision and rationale for the project, and provides a forum for people to share their thoughts about it.
Community members are saying that they want the new campus to have a more open footprint, one that is not insulated from the surrounding neighborhood. “We’re doing that in spades,” McDonald says. “We’re going to, hopefully, be a catalyst to revitalize the West 25th St. neighborhood.”
HKS Inc., Dallas, is serving as executive architect for the project. Shannon Kraus, senior vice president and managing director, HKS, says the firm has been researching ways in which neighborhood environments can impact community health. For example, he cites data released by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America that show life expectancy can vary significantly for people born just a few miles apart in certain U.S. cities.
“Community health is a big part of MetroHealth and our strategic plan,” McDonald says. The goal is to use the campus redesign to foster healthy lifestyles and encourage economic development in the area. Initial ideas range from building bike paths and a baseball field to creating a network of mixed-used buildings. “This project is big enough to drive investment,” Kraus notes.
Integrating the medical campus with the neighborhood may be a way to get closer to patients and make health care more accessible. “It’s core to the way that we have to reform ourselves, to be able to deliver health care and wellness care effectively,” McDonald says.
MetroHealth is a public hospital; its buildings are owned by Ohio’s Cuyahoga County. “We’re working very carefully and very closely with the government entities to figure out how we’re going to finance this rather large undertaking,” he says. The health system is spending some of its own money as capital, conducting philanthropic work and breaking the project into stages. Construction is scheduled to begin next year and finish in 2020.
A transformational steering committee that includes representatives from government; the neighborhood; and MetroHealth’s management, unions and board of directors is meeting “very frequently” to discuss the project and vote on decisions related to it, McDonald says.
He notes that MetroHealth has deferred a lot of facility work over the years, given the age of its buildings. Now, he says, “We have an opportunity to do it the right way, being able to think globally about how we want it to look. We have an opportunity to try to create something that’s well-thought-out and integrated. We’re very excited about it.”
Amy Eagle is a freelance writer based in Homewood, Ill., who specializes in health care-related topics.
Common Themes in Designing Health
Facility design can have a marked influence on an organization’s ability to increase efficiency and quality. In an effort to create care environments that help to provide better value, health systems are considering a number of approaches, ranging from renovating or expanding an existing hospital to building a new facility or even overhauling an entire medical campus.
Although design and construction solutions vary, there are common themes among health care providers who are assessing their facilities in light of current health care trends, says Will McConnell, vice president and regional practice leader, health care, from the Chicago office of design, architecture, engineering and planning firm HOK. These themes include:
• Improving inpatient environments to promote safety, incorporate technology and increase patient satisfaction, especially for older patients
• Moving care activity to lower-cost, ambulatory environments that can be more convenient for patients to access
• Considering the role of the emergency department and related facility components, such as observation units and clinical decision units, as observation periods are extended to determine the necessity of hospitalization
• Exploring ways to reduce facility costs, including lowering energy costs, renovating rather than replacing facilities and consolidating underutilized buildings — A.E.