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Weekly Overview

Week One

Overview

The topics and objectives for Week One focus broadly on the evolution of health care facility design. The desired outcome is for learners to be able to summarize high level processes and drivers associated with facility planning, design, and construction. The goal is to design facilities that meet the needs of a variety of stakeholders (e.g., physicians, nurses, administrators) and perhaps most importantly patients. Patient-centered and evidence-based design are key principles of delivering health care that is effective, efficient, and sustainable. Health care facilities across the country are largely unsustainable and do not meet the comprehensive needs of the population they are intended to serve. Today, patient-centered care focuses more on innovative approaches that include a variety of telemedince, holistic and preventive treatments, ambulatory verses inpatient services, and increasingly long-term care. Additionally, innovations like electronic medical/health records coupled with the proliferation of information technology, data, and global connectivity is transforming health care delivery.

What you will cover

1. Health Care Facility Design

a. Explain the evolution of health care facility design since the 1930s.

1) Economic conditions during the 1930s decreased the use of hospitals.

2) New government programs after World War II increased the use of health care.

a) Led to development of medical office buildings (MOBs)

b) Began an emphasis on ambulatory care

c) Outpatient clinics became popular by 1960s

3) Government grants in the 1940s led to construction of newer and larger hospitals.

4) In 1965, the passage of Medicare (Title XVIII) included capital funding reimbursement for hospitals, skilled nursing facilities, and other health care organizations.

a) Resulted in an increase in construction of skilled nursing facilities

b) Most designed based on the hospital model with patient rooms located off double-loaded central corridors

5) Beginning in the 1980s, Medicare began reducing reimbursement to health care organizations.

6) Prospective payment systems paid a fixed amount for services rather than reimbursing costs of care.

7) Reimbursement for capital expenditures was eliminated, which resulted in reduced availability of funds for new equipment, building construction, and renovation.

8) By the early 1980s, dissatisfaction with the skilled nursing model of care led to the development of assisted living facilities that were designed with features from hospitality (hotels); construction of retirement communities proliferated.

9) By the 1990s, the cottage design was introduced as a new model of care for the elderly, developmentally and intellectually disabled, Alzheimer’s patients, and others.

10) By 2000, newer hospital designs began to focus on the healing environment, evidence-based design, and sustainability.

b. Differentiate the types of health care facilities.

1) Types of health care facilities

a) Hospitals

b) Academic medical centers

c) Trauma center

1) Level of center

a) Level I: highest level, requires full scope of emergent care

b) Level II: augments Level I systems, no ongoing research or surgical residency program required

c) Level III: limited to no resources for emergency resuscitation, surgery, or critical care

d) Level IV: resource constrained in locations in which Level III criteria can’t be met

e) Level V: basic evaluation, diagnostic and stabilization services

d) Community hospitals

1) For adults

2) For children

3) For specialized services

a) Burn center

b) Birthing center

c) Bariatric

e) Psychiatric hospitals

2) Ambulatory services

a) Medical office building (MOB)

b) Physicians’ clinics

c) Freestanding diagnostic services

1) Radiology

2) Laboratory services

3) Pharmacies

d) Day surgery centers

e) Sports medicine treatment centers

3) Long-term care (LTC) services

a) Skilled nursing facilities

b) Assisted living facilities

c) Alzheimer’s and memory care facilities

d) Continuing care retirement communities

e) Adult day care facilities

f) LTC facilities for children or for treating obesity

g) Hospice

h) Home health agencies

4) Rehabilitation and wellness facilities

a) Acute rehabilitation facilities

b) Substance abuse facilities

c) Medical Spas

5) Psychiatric facilities

a) Inpatient

b) Outpatient or day treatment services

6) Dental facilities

7) Veterinary facilities

a) Veterinary clinic

b) Emergency veterinary hospital

c. Describe the role of stakeholders in facility planning and development.

1) Historical perspective on facility planning

2) Facility planning historically project driven

a) Based on staff or donor wishes, or promises to physicians

b) Abundant use of space without understanding of associated costs

c) Not tied to strategic plan, technology investments, or overall capital strategy

d) Approaches to avoid construction rarely considered

3) Today’s environment

a) There is now more focus on whether the new facility is patient-centered and sustainable (e.g., environmental and energy efficient).

b) Organizations are using a more comprehensive, integrated, data-driven, and evidence-based process.

c) Many current and future challenges exist that affect the way facilities are used, planned, financed, and built.

1) Fluctuating demand and use

2) Capacity constraints

3) Staffing shortages

4) Focus on patient safety

5) Increased importance of information management

6) Rapid changes in development of new technology

7) Rapidly rising costs

8) Aging facilities

9) Limited access to capital

4) A consumer-driven market: parties who should participate in predesign planning

a) The chief executive officer (CEO)

1) The chief operations officer (COO)

2) The building or facilities committee of the board of directors

3) Members of the management team

4) Key staff and physicians who will use the new facility

5) Architects, engineers, and construction companies

b) Importance of predesign planning

1) At this stage, the health care executive determines the right services, size, location, and financial structure.

d. Identify processes in space and facility planning.

1) The space planning process is robust.

a) Gather information about each department’s current space allocation.

b) Identify specific space needs of each department or activity, both current and future.

c) Consider issues related to adequate space, efficient work flow, optimum location, patient privacy, etc.

d) There are a number of tools used in the space planning process.

1) Relationship diagrams

2) Adjacency matrix

3) Interrelationship matrix

4) Bubble diagrams

5) Workload analysis

e) There are 10 facility configuration principles

1) Separate key types of campus traffic.

2) Clearly define the front door.

3) Coordinate and collocate customer intake and access services.

4) Optimize the use of prime real estate (near the front door).

5) Minimize the total number of outpatient destinations; group related clinical services near an intake area.

6) Position diagnostic and treatment services for changing technology and future operational flexibility by collocating services with similar facility needs.

7) Minimize inpatient transfers.

8) Unbundle high-volume, recurring outpatient services to an off-site location.

9) Move building support services to less expensive buildings.

10) Provide flexible, generic administrative office space.

f) The end result of the space planning process is a listing of required square footage per department or activity and a diagram of the best location for each activity from which the architect will create the facility layout.

2) Overview of facility planning includes six stages.

a) Predesign planning

b) Schematic design

c) Design development

d) Contract document development

e) Construction

f) Occupancy or move in

3) A rigorous planning process is important to the success of the project.

4) Opportunities to reduce the initial capital cost and the ongoing operational costs are greatest in this stage.

5) Good planning at this stage can assure long-range functional life for the project and future adaptability to changes in medical treatment, practice, technology, or models of care.

6) There is a decision and rationale process for new construction versus renovation

a) New construction (Replacement)

1) New construction offers a clean slate with a design that is constrained only by site, budget, and regulations.

2) Construction can be segregated from ongoing patient treatment activities.

3) The facility can be located where it is easily accessible to patients, physicians, and other stakeholders, which is an important issue if the population has moved away from the current facility.

4) New construction may require a certificate of need (CON) approval in some states.

b) Remodeling (Renovation) an existing facility

1) The design may be constrained by existing construction, location of load-bearing walls, plumbing, site characteristics, etc.

2) Hazardous materials, like asbestos, may need to be removed.

7) Decisions must be made regarding current patients.

a) Reduce population/patients and close down the area until remodeling is complete.

b) Stage remodeling around patient care.

1) This is often necessary in long-term care facilities, but it can be complicated to manage.

2) This may require scheduling some construction activities during the night shift.

8) Planning may require upgrading aspects of the facility that were not originally part of the remodeling project to meet current building codes and regulations.

9) Costs to remodel should be compared to the costs of new construction to determine whether the value received from the completed remodeling project justifies the expense.

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