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Rural Hospital Summer Rural Hospital Summer WorkshopWorkshop
June 24, 2008June 24, 2008
Construction Projects: Construction Projects: Strategy to Strategy to
Implementation Implementation
Health Facilities Planning & Development
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Jody CaronaJody Carona Health Facilities Planning and Health Facilities Planning and
DevelopmentDevelopment
Joe KunkelJoe Kunkel The Healthcare Collaborative GroupThe Healthcare Collaborative Group
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Setting the Stage… Setting the Stage… Creating the Vision Creating the Vision
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"I saw an angel in the stone, and I carved to set it free"
-Michelangelo
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First Things First: Strategic/Master First Things First: Strategic/Master Planning Creates the VisionPlanning Creates the Vision
SP Process: Quantification of – SP Process: Quantification of – Community need and demand-inpatient Community need and demand-inpatient
and outpatient and outpatient Market positionMarket position Medical staff Medical staff Community perceptionsCommunity perceptions Physical plant needs versus current Physical plant needs versus current
physical plant—major space drivers physical plant—major space drivers (beds, (beds, ED, ORs, etc.) ED, ORs, etc.)
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Visioning Is Also ImportantVisioning Is Also Important
May also require revisiting of vision and May also require revisiting of vision and mission statements. mission statements.
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Understanding Your Community’s Understanding Your Community’s Need and DemandNeed and Demand
What is the size of the market? What is the size of the market? How do you define your primary service area?How do you define your primary service area? Who else serves this market? Who else serves this market? How many admissions annually?How many admissions annually? How many ED visits, surgeries etc?How many ED visits, surgeries etc? How are demographics changing? What How are demographics changing? What
impact will this have on future need and impact will this have on future need and demand? demand?
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RegulatoryPressures
Reimbursement
DebtCapacity
Safety &Security
TechnologyAdvances
StaffShortages
EmpoweredPhysicians
OperatingMarginPressure
Consumerism
Demographics
Drivers ofChange
Times Are “A-Changing”Times Are “A-Changing”
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Demographics are a Major Driver of Demographics are a Major Driver of Future VolumeFuture Volume
Understanding demographics is key… Understanding demographics is key… Elderly use services at 2.5 times the rate of Elderly use services at 2.5 times the rate of
under 65.under 65. What assumptions do we want to make What assumptions do we want to make
about the future role of the hospital— about the future role of the hospital— service delivery, etc.?service delivery, etc.?
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Drill Down as Far as Possible….Drill Down as Far as Possible….
The ‘Typical’ Rural AreaThe ‘Typical’ Rural Area
20052005 %% (WA St)(WA St) 20102010 ChangeChange
Tot. Pop.Tot. Pop. 10,06110,061 10,16710,167 + 1%+ 1%
0-170-17 1,9941,994 20%20% 24%24% 1,8521,852 - 7%- 7%
Fem. 15-44Fem. 15-44 1,7111,711 17%17% 21%21% 1,7181,718 + 0%+ 0%
65 +65 + 1,8751,875 19%19% 12%12% 2,0432,043 + 9%+ 9%
Lower % of peds and OB Lower % of peds and OB womenwomen
Slow, steady growth overallFlat growth for peds and OB women
Rapid growth for seniorsHigher % of seniors
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Inpatient Market Position is Easy to Inpatient Market Position is Easy to Quantify Quantify
Inpatient:Inpatient: CHARS allows us to easily quantify size of CHARS allows us to easily quantify size of
inpatient market—by zip code of residence, inpatient market—by zip code of residence, patient age, DRG, and hospital/MD.patient age, DRG, and hospital/MD.• Can track changes in utilization and market share Can track changes in utilization and market share
over time.over time.• This data is key to projecting future inpatient bed This data is key to projecting future inpatient bed
needs. needs.
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Inpatient Market DataInpatient Market Data
Service LineService Line
20042004Avg. Avg. Annual Annual Chg. in Chg. in DaysDays1996-1996-20032003
Market Share of 2004 DaysMarket Share of 2004 Days
Disch.Disch. DaysDays ADCADC The The HospitalHospital
Hospital Hospital AA
HospitaHospital Bl B
HospitaHospital Cl C
Other Other HospitalHospital
ssTotalTotal
CardiologyCardiology 618618 1,5961,596 44 -1.67%-1.67% 28.5%28.5% 23.4%23.4% 18.4%18.4% 0.7%0.7% 29.0%29.0% 100.0100.0%%
General General MedicinMedicinee
785785 1,9001,900 55 1.39%1.39% 39.7%39.7% 22.4%22.4% 15.3%15.3% 3.3%3.3% 19.3%19.3% 100.0100.0%%
General General SurgerySurgery 352352 2,2252,225 66 1.00%1.00% 17.1%17.1% 8.9%8.9% 3.8%3.8% 6.2%6.2% 64.0%64.0% 100.0100.0
%%
OB/DeliveryOB/Delivery 326326 1,1071,107 33 2.55%2.55% 61.6%61.6% 22.8%22.8% 0.0%0.0% 0.5%0.5% 15.1%15.1% 100.0100.0%%
OrthopedicsOrthopedics 608608 2,0252,025 66 -0.81%-0.81% 24.4%24.4% 10.4%10.4% 2.0%2.0% 9.3%9.3% 54.0%54.0% 100.0100.0%%
OtherOther 225225 526526 11 0.36%0.36% 15.3%15.3% 9.6%9.6% 3.5%3.5% 2.4%2.4% 69.4%69.4% 100.0100.0%%
TOTALTOTAL 2,9142,914 9,3799,379 2626 0.52%0.52% 25.5%25.5% 13.8%13.8% 7.8%7.8% 4.5%4.5% 48.5%48.5% 100.0100.0%%
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But, We Continue to Struggle with But, We Continue to Struggle with the Ever Increasing Outpatient the Ever Increasing Outpatient
MarketMarket
OutpatientOutpatient Historically, much more difficult to quantify—Historically, much more difficult to quantify—
but “proxies” are possible via community but “proxies” are possible via community surveying and/or Solucient outpatient data. surveying and/or Solucient outpatient data.
Changes in outpatient as much a function of Changes in outpatient as much a function of technology and reimbursement as technology and reimbursement as demographics.demographics.
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Understanding Medical Staff Need Understanding Medical Staff Need and Current Situation is Also Key and Current Situation is Also Key
Should first compare community need for MD Should first compare community need for MD against supply. Are there unmet needs and against supply. Are there unmet needs and realistic opportunities?realistic opportunities?
Must also include existing MDs in process:Must also include existing MDs in process: Are they committed to staying in the community? For Are they committed to staying in the community? For
how long? how long?
Is there a need for a formal medical staff Is there a need for a formal medical staff development process. How much $$ will this development process. How much $$ will this require? require?
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Surveys are Often a Good Way to Surveys are Often a Good Way to Collect the Needed InformationCollect the Needed Information
Key Survey QuestionsKey Survey Questions Practice Data (visits, % at the Hospital, payer Practice Data (visits, % at the Hospital, payer
mix, etc.)mix, etc.) Practicing In/ Recruiting to the CommunityPracticing In/ Recruiting to the Community Perceived Manpower/Recruiting NeedsPerceived Manpower/Recruiting Needs The Hospital’s Role in RecruitingThe Hospital’s Role in Recruiting Specific Perceptions of the HospitalSpecific Perceptions of the Hospital
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Calculations of Need Should Calculations of Need Should Consider: Consider:
20102010 Avg. Pop.Avg. Pop. Net Phys.Net Phys.
to Phys.to Phys. Avg. Phys.Avg. Phys. Need: AgeNeed: Age
PhysicianPhysician Age Adj.Age Adj. Age Adj.Age Adj. Current Current Adj.-Current Adj.-Current
SpecialistSpecialist Ratio: 1 to-Ratio: 1 to- NeedNeed SupplySupply SupplySupply
Family/General Family/General PracticePractice 3,085 3,085
Internal MedicineInternal Medicine 4,452 4,452
PediatricsPediatrics 8,987 8,987
All Primary CareAll Primary Care - -
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How Does the Community Perceive How Does the Community Perceive the Hospital? Will they Support the Hospital? Will they Support
Growth and Development?Growth and Development?
Strongly consider a community survey Strongly consider a community survey and a series of key informant interviews.and a series of key informant interviews.
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How Does the Community Perceive How Does the Community Perceive the Hospital?the Hospital?
Community survey-will address issues of:Community survey-will address issues of: Utilization and patient satisfaction:Utilization and patient satisfaction:
Primary care practitionersPrimary care practitioners Specific outpatient services Specific outpatient services Inpatient servicesInpatient services Urgent careUrgent care SpecialistsSpecialists
Reasons for leaving the communityReasons for leaving the community Awareness/perceptions of HospitalAwareness/perceptions of Hospital Priorities for local health carePriorities for local health care Demographic info (insurance, etc.)Demographic info (insurance, etc.) Willingness to taxWillingness to tax Other issues as appropriateOther issues as appropriate
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How Does the Community Perceive How Does the Community Perceive the Hospital?the Hospital?
Key Informant Interviews:Key Informant Interviews: Perceptions of hospital, hospital leadershipPerceptions of hospital, hospital leadership Role of hospital in the communityRole of hospital in the community Other divergent/convergent issues facing Other divergent/convergent issues facing
the communitythe community Future vision for the hospitalFuture vision for the hospital
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The End Result….The End Result….
Clear goals and direction.Clear goals and direction. Clear delineation of space needs at Clear delineation of space needs at
varying market share assumptions.varying market share assumptions. Must take the next step of comparing Must take the next step of comparing
existing plant to projected needs.existing plant to projected needs.
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Demographics
Gross Volumes
SpecificVolumes
Operating P&LSpace & CapitalRequirements
Financial Model Logic Flow
FILTERS:-Clinical-Volume-Market Share-MD Availability/Supply-Support-Financial
Drivers:-Population Projections-Age/Gender-Utilization History
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From Strategy to From Strategy to Implementation Implementation
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Major Facilities DirectionsMajor Facilities Directions
Replacement Major Expansion Minor Expansion
Existing Facility Existing Faculty
Major Expansion
New
NewNew
New Replacement
Existing Facility
High CostLong DurationLarger System wide Strategic Decision
High CostMedium Duration
Lower CostShorter Duration
New
1 2 3
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Environment
Market Analysis and Plan
Operational Design
Physician Develop
PatientExperience
FinancialPlan
Technology
Hospital Expansion/ Renovation
Plan
Vision & Strategy
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Getting OrganizedGetting Organized
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Project Structure Chart
CMO COO VP ITVP HREquipment Planner THCG VP MARKETINGPROPERTY MANAGER
Hospital Leadership
Physician Leaders
Architect
THCG
VP HRVP IT
Equipment PlannerProperty ManagerMission Services
CEOVP
CMOCOOCFO
VP Support ServicesVP Marketing
HospitalSTEERING COMMITTEE
VisionBaseline AssumptionsPolicyStrategyImageBudget
STAFFInternal Project Lead
WORKING GROUPS
Report to Steering Committee
User Group Leadership& Communication
Operational Concepts & Philosophies
Physician Development
OPS Planning Design
EquipmentPlanning
HumanResources
InformationTechnology
ProjectDevelopment
CommunityRelations &
CommunicationMOB
Physician Need Analysis
Recruitment Strategy
Medical StaffDev’t/Priviledging/Credentialing
Establish Adjacencies& Flow
Department Design
Room by room equipment planning
Procurement Strategy
Overall staffing strategy
Training
Leadership Development
Overall IT Strategy
Telecom, Voice/Data
Low Voltage
Access Control
Clinical Applications
Day to day managementof construction process
Public Approvals
Design Control
Budget/Schedule
Q/C
Developer Selection
MOB Development
Leasing
Internal Communication
External PR/Image
Community Health/Mission Integration
Fundraising
USER GROUPSLOCAL JURISDICTIONDesign ReviewBuilding DepartmentFire Marshall
STATEDOH
MOBDeveloperPhysicians
HOSPITALDx & TxEmergencyInpatient ImagingOutpatient ImagingCardiac CathLabSurgeryPT/OTRehab TherapyResp Therapy
SUPPORTCentral SterilePharmacyMat. Mgmt/Recycle/DocHousekeepingAdmittingPre-Admission TestingMedical RecordsGift ShopChapelPublic SpacesHospitality/ValetAdministrationDietaryConf/Med Ed/Library
PATIENT BEDSMed/SurgICUStep DownShort StayPACUPrep/Hold
OTHERPlant/EngineeringSecurityIT/TelecomParkingInfection Control
Space & Equipment NeedsRoom DetailsRoom Function & ConfigurationOperationsCurrent/Future Needs
Hospital Leadership
Physician Leaders
Architect
THCG
Hospital Leadership
Physician Leaders
Architect
THCG
Hospital Leadership
Physician Leaders
Architect
THCG
Hospital Leadership
Physician Leaders
Architect
THCG
Hospital Leadership
Physician Leaders
Architect
Contractor
Hospital Leadership
Physician Leaders
Architect
THCG
Hospital Leadership
Physician Leaders
Architect
THCG
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Visioning Visioning
Different than Strategic VisionDifferent than Strategic Vision Set Guiding Principles for ProjectSet Guiding Principles for Project
Overarching common attributesOverarching common attributes• SafetySafety• Flexibility v. expandabilityFlexibility v. expandability• EfficientEfficient• HealingHealing• Recruitment/retentionRecruitment/retention
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VisioningVisioning
Set MetricsSet Metrics Measurable goalsMeasurable goals Project-specificProject-specific S-t-r-e-t-c-hS-t-r-e-t-c-h Project-influenced goals as wellProject-influenced goals as well
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Keys to a Successful ProjectKeys to a Successful Project
Communication, Communication, Communication, Communication, CommunicationCommunication
Set of written “Working Assumptions”Set of written “Working Assumptions” Clear Decision-MakingClear Decision-Making Regular UpdatesRegular Updates
WrittenWritten PhonePhone In-personIn-person
Project Management – Project Management – Owner/Architect/ContractorOwner/Architect/Contractor
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Design – Getting it RightDesign – Getting it Right
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Prioritization of FLOW in DesignPrioritization of FLOW in Design
Objective Subjective
Patient VolumeProfitability
Strategic Importance
Growth
BrandCompetition
Physician RelationsCommunity Disruptive Tech
Staffing Intensity
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Design IssuesDesign Issues
Clear Space ProgramClear Space Program Master Planning – Long-TermMaster Planning – Long-Term Project Design – Short-TermProject Design – Short-Term Mock-ups and Other ToolsMock-ups and Other Tools
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Establishing a Project BudgetEstablishing a Project Budget
LandLand EntitlementsEntitlements ConstructionConstruction EscalationEscalation ““I” v. “B”I” v. “B” Soft CostsSoft Costs ContingenciesContingencies
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Land CostsLand Costs
Purchase PricePurchase Price Criteria for DevelopmentCriteria for Development Time HorizonsTime Horizons Location, Location, LocationLocation, Location, Location Infrastructure & EntitlementsInfrastructure & Entitlements TimeframesTimeframes
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ConstructionConstruction
Market CompsMarket Comps EscalationEscalation ““I” v. “B”I” v. “B”
CostCost FlexibilityFlexibility ReimbursementReimbursement
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Soft CostsSoft Costs
Cost the Same as Hard Costs!Cost the Same as Hard Costs! Design FeesDesign Fees EngineeringEngineering Project ManagementProject Management Jurisdictional FeesJurisdictional Fees
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Owner’s CostsOwner’s Costs
Medical Equipment (and Planning)Medical Equipment (and Planning) Furniture/Fixtures/EquipmentFurniture/Fixtures/Equipment Information TechnologyInformation Technology
CablingCabling ApplicationsApplications
ContingenciesContingencies
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Do the MathDo the Math How many by specialtyHow many by specialty Lead times/degree of difficultyLead times/degree of difficulty Population-based v. facility-basedPopulation-based v. facility-based ““Need” v. “redistribution”Need” v. “redistribution” Don’t be “beggars”Don’t be “beggars” Pool of potential staffPool of potential staff Open process/project structure/communicationOpen process/project structure/communication Exclusives/RFP’sExclusives/RFP’s
MD Development & MD Development & RecruitmentRecruitment
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Think CreativelyThink Creatively
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In the End……..In the End……..