Top Ten Considerations When Renovating Your Patient Tower
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Transcript of Top Ten Considerations When Renovating Your Patient Tower
TOP
TENCONSIDERATIONS WHEN RENOVATING YOUR
patient TOWER
© K
evin
G R
eeve
s
© Scott Pease
© Kevin G Reeves
© Tom Crane
© B
lake
Mar
vin
While the many benefits of caring for patients within a private room have been understood for decades now, there are still thousands of patients who still receive care outside of this clinically preferred environment on a daily basis. As is often the case, the benefits may be clear, but the perceived cost of providing more private patient rooms has prevented the wholesale adoption of this basic principle throughout the United States. Building new bed towers has been an option for systems that could afford the construction costs, however, many hospital systems do not have that luxury or are landlocked and cannot expand.
In addition, the uncertainty of the Affordable Care Act reimbursement landscape has certainly contributed to stalling the move toward 100% private rooms.
On the surface, the alternate solution should be readily apparent. The trend toward outpatient care continues to limit inpatient stays, thus reducing the number of required beds in many areas of the country. So why not simply remove one bed from each semi private room while this might be the expedient solution, as is often the case, the expedient solution may not be the most appropriate solution.
There are a variety of considerations that need to be thoughtfully addressed when converting semi-private rooms to private – and more often than not, some level of physical alteration is needed to address these issues. Recognizing “necessity is the mother of invention,” the Array Thought Leadership team developed this top ten list of considerations to help healthcare organizations develop effective plans when considering renovating/converting semi-private bed units into private bed units.
6
operational efficiency considerations
Conventional wisdom historically has supported the notion that a typical medical/
surgical unit operates most efficiently within a range of 24 to 36 patient beds per
unit. Depending upon the size of the existing unit, it can be challenging to achieve
these ideal ratios when converting to all private room model.
By implementing Lean Design principles with your architect during design, you can
identify potential staff inefficiencies posed by the renovation. This includes activities
to help users see through a new set of lenses and redesign processes for maximum
efficiency. In essence, the work is addressing the fundamentals of what happens
in the workplace to ensure all the resources or “flows” come together in the right
place, in the right quantity and at the right time to support the care provided without
error. The last thing you want to do is renovate your patient floors to reflect the “work
arounds” your staff has developed.
Lean activities include on-site observation and preparing spaghetti mapping
diagrams to identify existing bottlenecks, so that a virtual optimized “future state”
can be developed. Utilizing a Lean Design approach allows the design team to fully
understand the operational issues that must be supported in the renovated space.
Your design team should match their methods to the healthcare organization’s level
of lean proficiency. Your architect should assess factors, including client leadership
beliefs and approach to workflow improvement, the existence of infrastructure to
support process improvement and the ability of the design team to collaborate and
integrate lean concepts. The assessment should drive the scope of the work.
••• Misalignment of the care model and the physical layout can mean a design that doesn’t support the way staff work and could even inhibit them.
7
© B
lake
Mar
vin
8
logistical considerations
It is tempting for hospital facilities to simply change the door signage of a semi-
private room, paint the walls and call it a day. But experience has demonstrated that
this is not a long-term solution due to the impact on the operational model when
converting to a private bedroom model.
More often than not, physical alterations are required in order to facilitate efficient
operations of a transformed inpatient care unit. The artistry is in determining the
appropriate level of renovation required, and in developing a plan to effectively
execute the renovation in a manner that minimizes any disruption of the day-to-day
hospital operations. The specific circumstance of any given renovation situation will
drive many of the detailed decisions, but there are common elements that transcend
these variations.
For example, the proper phasing of a renovation project is essential to its success.
Assuming there are a number of floors to be renovated in a single wing, there are
choices that can be made to limit the impact of the construction on the operations.
For instance, it may make more sense to renovate a few rooms at a time on multiple
floors (stacked together) as opposed to closing down an entire floor for construction.
This stacked phasing model allows the above ceiling construction to occur in a
single area without the same above ceiling disruptions that occur when renovating a
horizontal wing – one floor at a time. Building Information Modeling (BIM) can be used
to assist in the modeling of renovation scenarios by adding a 4D element (time) to
simulate the sequencing of construction, thus enabling stakeholders to make better
decisions when developing and finalizing the construction phasing plan.
••• Vertical Stacked Phasing
••• Horizontal Stacked Phasing
© Scott Pease
9
10
life safety considerations
Providing a safe environment for patients, staff, family and
visitors is clearly the utmost priority – and responsibility - of
any healthcare organization. Turning an operating nursing
unit into a temporary construction site creates numerous
environmental challenges that can only be addressed with
proper planning and execution of a well-conceived plan that
incorporates proven interim life safety measures (ILSM).
A properly planned and executed ILSM will result in zero
disruptions to patient care and hospital operations. In basic
terms, “life safety measures” are health and safety features
designed to protect the safety of patients, visitors and staff
who work in the hospital facilities, including specific safety
features such as egress corridors, exit signs, fire protection
systems (smoke detectors, sprinklers, fire extinguishers and
fire alarm systems), smoke barriers, emergency evacuation
plans and many other items.
These features are often compromised during construction
within an operating facility, so the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) developed
Interim Life Safety Measures to protect the safety and health
of patients by compensating for any hazards caused by
construction activity.
There are main steps in the planning and implementation of
ILSMs: (1) Pre-construction Assessment, (2) Development
and Daily Monitoring of an ILSM Compliance Checklist and (3)
Close-out of the ILSM to transition back to standard operating
procedures. An effective ILSM program includes a champion
to lead this important aspect of a project, and should also
include a training program that communicates the importance
of the ILSM program to all stakeholders in the planning,
construction and operation of the affected facilities.
••• The Interim Life Safety Measure Compliance Checklist is a tool that can be used to assist you with monitoring and documentation of project ILSM performance.
Taking a fire alarm system out-of-serviceTaking a sprinkler system out-of-serviceDisconnecting alarm devices
MAINTENANCE AND TESTING
INTERIM LIFE SAFETY MEASURE
Hazardous areas not properly protected
CODE DEFICIENCIES
CONSTRUCTION
Blocking off an approved exitRerouting of traffic to emergency roomMajor renovation of an occupied floorReplacing fire alarm system (out of service)Installing sprinkler system ( out of service)Significantly modifying smoke or fire barrier wallsAdding an addition to an existing structure
Excessive travel distance to an approved exitLack of two remote exitsNonconforming building construction typeImproperly protected vertical openingsLarge penetrations in fire barriersCorridor walls do not extend to the structure
Post
alte
rnat
ive
exit
sign
age
Patient room door latching problemLacking a code complying smoke barrierFire exit stairs discharge improperly
Addi
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Insp
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uild
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ies
Not
ify fi
re d
epar
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Initi
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EXISTING LIFE SAFETY CODE DEFICIENCIES OR CONDITIONS AS A RESULT OF
CONSTRUCTION
Insp
ect e
xist
s da
ily
Tem
pora
ry fi
re a
larm
and
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Addi
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Tem
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Incr
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Enfo
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usek
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Addi
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11
It’s more than just
your hands.WASHING 12
infection control considerations
Hospitals started paying attention to infection control in the
late 1880s, when mounting evidence showed unsanitary
conditions were hurting patients. While hygiene in hospitals
has been a great concern ever since, and significant
improvements have been made, an estimated 1 in 20 patients
still pick up infections they didn’t have when they first arrived
at a hospital. Add construction activity to the mix, and the
challenge to keep patients free of infection becomes even more
challenging. The most common microbes associated with
construction activity are Aspergillus, a fungus found in dust,
soil, moisture and mold; and Legionella, a bacterium found in
water. These can cause serious infections if measures are not
taken to mitigate this risk.
The Facilities Guidelines Institute recognized the importance
of this issue by adding an entire section to the 2010 Guidelines
for Design and Construction of Health Care Facilities dedicated
to the infection control risk assessment (ICRA). ICRA is a
multidisciplinary, documented assessment process intended to
proactively identify and mitigate risks from infection that could
occur during construction activities.
This process identifies and takes into account the patient
population at risk, the nature and scope of the project and the
functional program of the healthcare facility. ICRA determines
the potential risk of transmission of various air and waterborne
biological contaminants in the facility. Plans for preventive
measures, barriers, monitoring and cleaning need to be
implemented to minimize exposure.
Typical issues covered in ICRA include: (1) mitigation of dust
and debris from construction activity with sealed plastic and
drywall barriers, (2) maintenance of negative air pressure
within construction areas to prevent the migration of dust,
(3) isolation of HVAC systems to prevent contamination into
patient areas, (4) controlled transportation and disposal of
construction debris in covered carts, away from air intakes,
(5) isolation, flushing and decontamination of water systems
affected by construction, (6) regular cleaning of the worksite
and (7) testing and inspection of construction areas and related
systems to confirm safety for patient use, as well as many more
issues that may be specific to the unique aspects of any given
renovation program.
The most effective ICRA process is collaborative, including all
project stakeholders. The process should start well before
construction begins, and only conclude when the environmental
conditions have been confirmed to be safe in the newly
renovated areas by the standards set forth in the ICRA process.
13
A safe environment
higher HCAHPS scores
HAPPY PATIENTS
14
patient safety considerations
Just because you are not starting with a “clean slate” as you would when designing
a new patient tower, it is important to remain open-minded when planning a patient
floor renovation. Yes, there may be budget constraints, but don’t allow the existing
room layout to limit opportunities to increase patient safety and satisfaction.
Studies show that patients recover more quickly if they are encouraged to restore
their independence. Many older patient rooms were designed when patients were
encouraged to remain and recuperate in bed with little or no consideration to support
mobility. Patient rooms today are designed to promote healing and feature elements
to support restoring a patient’s ability to move about and regain their independence
and confidence.
Typically, hospital falls occur most often when patients attempt to get to the
bathroom. So in your renovation, if your headwall is not located on the wall closest
to the bathroom, consider relocating the headwall or the bathroom so the patient
doesn’t have to cross an open floor. Consider installing multiple lighting options,
including embedded floor lights leading to the bathroom, controlled by the patient’s
pillow switch to reduce falls and injuries due to room darkness. Another key patient
satisfier is having the ability to control the window shades.
One of the most common complaints in any hospital is noise. When renovating a
patient floor, consider noise reducing design elements such as rubber floors, thicker
carpets and acoustic panels. This would also be an excellent time to review your
equipment and alarm system configuration. Don’t just accept default alarm settings,
adjust them to specific patient acuity.
All of these design considerations and interior elements contribute to not only a safer,
but more pleasant hospital stay, which will translate into higher HCAHPS scores.
••• The sheer number of alarms that sound throughout the day can cause serious consequences from alarm fatigue for clinicians.
© Scott Pease
© Scott Pease
15
16
engineering considerations
Often, business leaders refer to facilities as the “bricks and mortar” part of their
operation. When it comes to healthcare facilities, it is not uncommon to invest more
in “air and water” than “bricks and mortar.” Heating, Ventilating, Air Conditioning,
Plumbing and Electrical Engineering systems can often account for well more than
50% of the cost of any given renovation project.
Of all these top ten considerations, this is probably the most challenging to address
without considerable upfront investment to determine the specific condition of the
facilities in question. Hidden above the ceiling and behind the walls are thousands
of linear feet of piping, conduit, ductwork and equipment that are in some respects
similar to the vital organs within the human body. We cannot see them, but we know
they are important.
A comprehensive facility condition assessment can go a long way towards shedding
some light on what otherwise could remain a mystery until uncovered during
the construction phase of a renovation project – when surprises are expensive.
Renovation projects can often provide the ideal opportunity to correct facility
deficiencies, and under the right circumstances can actually pay for themselves
through improved operational costs that will be realized over the life of the facility.
For example, an outdated/inefficient HVAC system could be replaced with a state-
of-the art system (with energy efficient controls). A life cycle analysis would
demonstrate how many years of energy savings it would take to essentially pay for
the one time capital improvement costs. Furthermore, a patient bed tower renovation
project provides an ideal environment to effectively replace key systems, while the
controls are in place to accommodate the primary construction activities underway.
© Jeffrey Totaro
17
ARE NOT THE ANSWER
© S
cott
Pea
se18
IT infrastructure considerations
In the wake of healthcare reform, with its emphasis on EMRs and Meaningful Use
implementation, IT Infrastructure has become be a larger line item of hospital capital
budgets and will remain so for the next 10 years as CMS reimbursement encourages
ACOs and bundled payments. Clinical Integration Networks (or CINs) will be required
to allow caregivers across the spectrum of care access to the data of patients that will
live longer and may require a higher level of care.
Because medical technology is one of the fastest advancing industries in the world,
your architect should assess the scope and magnitude of your renovation project
and its impact. If it is a simple upgrade, or an individual floor renovation, the project
can be evaluated individually, but if you are planning an entire tower upgrade, you
may consider a more comprehensive approach that relocates “soft functions” into
the oldest, tightest areas, in order to open up adequate space to accommodate the IT
infrastructure necessary to support evolving technology. Initial costs may be higher,
but you will be well positioned for future advancements.
When converting older, smaller units, often there is not enough square footage
available on the patient floor to “fit everything in.” As clinical activities and
communication move to dashboards, coupled with the rise of hand-held BYOD (Bring
Your Own Device) which largely applies to physicians for now but will undoubtedly
increase in the future, renovations need to incorporate alternate access modes
complementary to traditional PC nodes (i.e. secure WiFi, wall-mounted touch screens,
large panel displays with updating/scrolling info) and provide space for the IT
infrastructure required to support it. As EMR access becomes the hub of all activity
on the floor, providing frequent, comfortable, convenient and reasonably private
access points is critically important.
19
ACCESSibility
is more than just clearances
20
© Scott Pease
© Scott Pease
© H
alki
n M
ason
accessibility considerations
Perhaps one of the most vexing elements of upgrading a
patient tower is addressing accessibility issues. This is due
in large part to the many different regulations and oversight
organizations. The original American with Disabilities
Act (ADA) and the revised Act effective March 15, 2011,
guarantees the civil rights of all disabled people, and is not
just limited to physical disabilities. In the summer of 2012,
the Department of Justice and Attorney General announced
a new, joint-enforcement program called the “Barrier-Free
Health Care Initiative” with the goal of ensuring that persons
with disabilities have access to medical information as well as
physical access to medical buildings.
The initiative addresses many aspects of healthcare
environments and services, such as facilities, diagnostic
equipment, websites, parking, transportation, information
in alternative formats, videophones and sign language
interpreters. Another caveat: be aware that the ADA standards
are enforced as civil rights violations and are separate from
building code violations.
This “mish mosh” of regulations impact patient tower
renovations on multiple levels. The best advice: anticipate
the needs of disabled patients during their entire hospital
stay while in the planning phase. Try this tip: during design
try to visualize the entire path of travel from the drop-off point
to the patient’s destination. Referred to as the “ADA Path of
Travel” requirement, this technique will help you incorporate all
codes: parking, drop-off, entrances, protruding objects along
corridors, toilet rooms, signage and alarms. Note: ADA codes
apply to most employee as well as public areas.
Note, meeting minimum ADA standards leaves no place for
dispensers, trash receptacles and supply tables without
compromising the clear maneuvering space required for
caregivers to assist a patient. Also, meeting ADA minimum
standards does not address bariatric design. With the
increased obesity in the general population, patients, staff and
visitors require larger door widths, as well as stronger toilets,
grab bars and chairs.
A valuable lesson learned from experience: while architects
design correctly and meet all code requirements, make
sure your contractor follows the design. Often contractors
construct to the standards they have used for generations, and
toilets are installed too far from the wall, grab bars are placed in
the wrong location and sink details are not followed resulting in
constricted knee space underneath. These construction errors
create functional difficulties and code deficiencies that can be
very expensive to correct.
ACCESSibility
is more than just clearances
21
© S
cott
Pea
se
Can you make your father’s
OLDSMOBILE run like a
PRIUS?
22
sustainability considerations
As citizens of the planet, this data alone should encourage all hospitals to investigate
all sustainable options possible in the design and construction of their facilities.
While achieving Silver or Gold LEED Certification on your patient tower renovation
project may set the sustainability bar a bit too high, there are many incentives and
options for pursuing environmentally-friendly design choices that could achieve LEED
certification.
First, investigate all opportunities to recycle your construction waste. There are
many organizations who will literally take the waste off your hands. The secret: early
coordination meetings with the entire team (owner, architect, contractor) to identify
materials that can be up-cycled to a non-profit organization and select items to be
recycled, all with the goal of reducing the amount of waste being sent to the landfill.
Second, identify design and engineering options that reduce electricity and water use.
For example, in a multi-floor renovation, sizing air-handling units to serve additional
floors, even those not being renovated, could increase efficiency, lower heating and
cooling costs as well as improve the indoor air quality.
Lastly, focus on selecting sustainable project materials that support high indoor
environmental quality (IEQ). On a recent two-floor hospital renovation project in New
Jersey, 13 of 35 LEED points were in the IEQ category. Ask your architect to research
materials such as doors and carpets that can be purchased within 100 miles of your
hospital - it will result in additional LEED points.
A combination of these strategies could contribute to LEED certification. Several of
these green building strategies may cost more initially, but if healthcare executives
can get over the short-term fiscal hurdle, the dividends for both the hospital and
environment could be huge later on.
The typical hospital uses as much energy in a year as 3,500 households.
This energy consumption has substantial carbon dioxide and operational
cost impacts, equal to the emissions of 5,950 cars on the road each year,
at an average annual cost up to $4,000,000.
••• Source: US EPA Greenhouse Gas Equivalences Calculator.
Electricity Rate $.11/kwh (US National Average 2012)
The typical hospital uses as much water in a year as 350 households
of 3 people. This water demand has substantial environmental and
operational cost impacts, equal to filling a bathtub 1,000,000 each year
at an average annual cost up to $800,000.
••• Source: Water supply and sewer rates, $7 and $9 /100 gallons
(2012)
23
“We’re all in this TOGETHER.”
24
© Blake Marvin
patient/family-involved care considerations
The concept of patient-centered and family-involved care is self-evident, and simply
put, the way that healthcare should be delivered. However, many of the hospitals
considering renovating their patient floors were not designed for the healing of patients
and comfort of family. Consider, for example, how the focus of many older hospital
rooms is the somewhat frightening medical equipment, while the halls throughout are
painted in practical, hospital green with noisy, but easy-to-clean linoleum floors.
As you consider renovating an outdated patient tower, you will have an opportunity to
re-invent the patient experience. Remember to provide spaces that offer a range or
hierarchy of interaction for patients, staff and families that range from interactive to
private. Examples include:
• A lobby or cafeteria (public)
• A chapel or reference library (semi-public)
• A family lounge (semi-private)
• A patient room or consultation area (private)
Again, use visualization techniques or process mapping to document the patient and
family experience from admission through checkout. Your goal, and what you should
ask your architect to do, is reduce or eliminate all barriers between patients and
clinicians so the physical environment supports the care giving process, empathy
and education about their condition. In a renovation, you have the opportunity to
reconfigure the patient room to allow family members — historically viewed as
operationally inconvenient — to become true partners in their loved one’s care.
Evidence points to the real benefits of healthcare facilities designed around patient,
family and staff needs and preferences. These benefits not only improve patient
outcomes and increase staff effectiveness and morale, they also help administrators
meet key safety goals, reduce costs and increase market share.
25
© Scott Pease
© Jeffrey Totaro
© Scott Pease
© Kevin G Reeves
CHECKPOINT
Discovery
Analysis
We believe healthcare design projects must focus on providing high value solutions that support best practices, foster collaboration, promote outstanding patient experiences and anticipate future flexibility. Working together with you, we map an optimal future work flow and patient experience through process mapping, operational planning, virtual mock-ups and simulation modeling as we work to develop a comprehensive project that supports your mission of caring for your community.
OUR APPROACH
PROCESS-LED LEAN DESIGN
26
CHECKPOINT CHECKPOINT CHECKPOINT
AnalysisCreation
Solution
27
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