SpaceMed Newsletter

Prudent Health System (PHS) planned to construct a new outpatient building to provide space for urgent care, ambulatory surgery, and various hospital-sponsored clinics on its main hospital campus. Space was needed to accommodate the following ten-year workload projections and corresponding clinical services:

Urgent care center with 32,000 annual visits
Ambulatory surgery center with 4,200 annual surgical cases
Hospital-sponsored clinics:

Medicine (23,000 annual visits)

Surgery (15,000 annual visits)

Neurosciences (6,000 annual visits)

Orthopedics (16,000 annual visits)

In addition, a small express testing area was planned to consolidate routine, quick turnaround outpatient testing in a single area ― including X-ray, EKG, and specimen collection ― along with a small satellite laboratory.

A room-by-room space program was prepared based on the projected workload and other functional planning assumptions provided by PHS ambulatory care staff. An initial schematic drawing was developed by the design architect and the project cost was estimated. A business plan was then prepared along with a financial pro forma analysis.

Due to the large amount of space programmed and corresponding high project cost, and high operational costs relative to the projected incremental revenue, PHS’s Chief Financial Officer asked the executive team whether they really needed a “Hummer” when a “Toyota” might suffice. The executive team agreed to evaluate the impact on overall space need (and resulting capital and operational costs) of planning a “lean” facility versus a more “generous” facility.

PLANNING APPROACH

The executive team reviewed the original operational assumptions documented in the functional program. In conjunction with the facility planning consultant, they identified several key factors that could reduce the overall size and cost of the new outpatient facility:

Operational assumptions. Operational processes were reengineered to increase the exam/procedure room turnaround time and the weekly hours of operation were expanded ― resulting in the need for less exam and procedure rooms. In addition to more efficient space utilization, customer service would also be enhanced.
Configuration of the clinics. The clinics were originally programmed based on their current organization and located in four distinct physical areas on the hospital campus. By combining the medicine, surgery, and neurology clinics into a single shared clinic, improved space utilization and staffing efficiencies would be possible. The new configuration also allowed the orthopedic clinic to be located on the first floor thus eliminating one of the X-ray rooms and facilitating coverage by the radiology techs working in the express testing area.
Size of exam/procedure rooms and offices. Based on a review of its existing facilities, PHS determined that it did not need such generously-sized exam rooms and offices ― for example, the clinic exam rooms were re-programmed at 100 net square feet (NSF) versus 120 NSF as originally programmed.
Facility design and layout. Alternate facility layouts were evaluated that resulted in less space required for intradepartmental and public circulation corridors. Along with two less floors, this substantially reduced the amount of department gross square feet (DGSF) and building gross square feet (BGSF).

COMPARISON OF FACILITY PLANNING ASSUMPTIONS

A summary of the assumptions used for the lean versus the more generous space planning approach is shown below:

	GENEROUS	LEAN
Urgent Care Center 32,000 Annual Visits	Staffed for limited weekly hours Average exam/treatment room turnaround time of 120 minutes Generously-sized exam/ treatment rooms and offices Private provider offices Generous NSF to DGSF space conversion factor	Staffed for extended weekly hours Average exam/treatment room turnaround time of 75 minutes Moderately-sized exam/ treatment rooms and offices Shared provider offices Moderate NSF to DGSF space conversion factor
Ambulatory Surgery Center 4,200 Annual Surgical Cases	Staffed for limited weekly hours Average of 3.5 surgery cases per OR per day Generously-sized procedure rooms and prep/recovery bays Generous NSF to DGSF space conversion factor	Staffed for extended weekly hours Average of 6.0 surgery cases per OR per day Moderately-sized procedure rooms and prep/recovery bays Moderate NSF to DGSF space conversion factor
Orthopedic Clinic 16,000 Annual Visits	Staffed 48 weeks per year Average exam/treatment room turnaround time of 45 minutes Generously-sized exam/ treatment rooms and offices Dedicated X-ray room Private provider offices Generous NSF to DGSF space conversion factor	Staffed 50 weeks per year Average exam/treatment room turnaround time of 40 minutes Moderately-sized exam/ treatment rooms and offices X-ray room shared with express testing area Shared provider offices Moderate NSF to DGSF space conversion factor
Other Clinics: Medicine Clinic Surgery Clinic Neurology Clinic 44,000 Annual Visits	Staffed 48 weeks per year Three separate clinics with varying daily hours of operation and exam/treatment room turnaround times Four consult rooms and two larger testing/procedure rooms Generously-sized exam/ treatment rooms and offices Private provider offices Generous NSF to DGSF space conversion factor	Staffed 50 weeks per year Shared clinic space with an average exam/treatment room turnaround time of 35 minutes Two consult rooms and one larger testing/procedure room (shared) Moderately-sized exam/ treatment rooms and offices Shared provider offices Moderate NSF to DGSF space conversion factor

COMPARISON OF SPACE NEED

The resulting space need is summarized in the following table based on the actual room-by-room space programs. In the lean scenario, 40,000 BGSF less space is required to accommodate the same projected annual workload.

	Space Program Summary
Facility Component	GENEROUS	vs.	LEAN
Urgent Care Center	15,000		8,600
Ambulatory Care Center	22,000		12,000
Orthopedic Clinic	6,200		4,400
Medicine Clinic	7,500		---
Surgery Clinic	5,500		---
Neurology Clinic	5,900		---
Shared Clinic	---		8,000
Express Testing Area	3,800		3,800
Entrance Lobby	3,200		3,200
Total DGSF	69,100		40,000
DGSF to BGSF Conversion Factor	1.30		1.25
Total BGSF	90,000	vs.	50,000

CONCLUSION

With 40,000 BGSF less space required in the lean scenario ― to accommodate the same projected annual workload ― the estimated project cost would be significantly reduced, particularly since the new space program can be accommodated with only two floors versus four as originally planned.

GENEROUS Ambulatory Care Facility 90,000 BGSF
	Building Section Diagram
LEAN Ambulatory Care Facility 50,000 BGSF
	Building Section Diagram

The PHS executive team eventually decided to construct the smaller, lean facility which would also be less costly to operate over time than the more generous facility. Moreover, the cost savings allowed the building to be designed to facilitate future horizontal as well as vertical expansion as required. back to top

Cynthia Hayward, AIA, ACHA, FAAHC

Principal

Hayward & Associates LLC

chayward@hayward-assoc.com

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In the News

USP 797 Impacts Pharmacy Space and Design

OVERVIEW

USP 797 is a regulation that governs any pharmacy that compounds sterile preparations including centralized and satellite hospital-based pharmacies, outpatient pharmacies, and off-site pharmacies. USP 797 is designed both to cut down on infections transmitted to patients through pharmaceutical products and to better protect staff working in pharmacies in the course of their exposure to pharmaceuticals. Issued by U.S. Pharmacopeia (USP), USP 797 has been endorsed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) who expects that organizations will be in full compliance by January 2008.

PHARMACY CLASSIFICATIONS

If the pharmacy being planned will be compounding sterile preparations, it must be categorized into one of the following classifications in order to determine the facility requirements for compliance with USP 797:

Low-risk level of compounding includes single transfers of sterile dosage forms from ampoules, bottles, bags, and vials using sterile syringes with sterile needles, other administration devices, and other sterile containers, and manually measuring and mixing no more than three manufactured products to compound drug admixtures.
Medium-risk level of compounding includes the compounding of total parenteral nutrition fluids using manual or automated devices, filling of reservoirs of injection and infusion devices with multiple sterile drug products or volumes of sterile drug solutions, and transfer of volumes from multiple ampoules or vials into a single final sterile container or product.
High-risk level of compounding includes dissolving nonsterile bulk drug and nutrient powders to make solutions which will be terminally sterilized, measuring and mixing sterile ingredients in nonsterile devices before sterilization is performed, and where sterile ingredients, components, devices, and mixtures have been exposed to air quality inferior to ISO Class 5 (maximum of 100 particles per cubic foot).

FACILITY REQUIREMENTS

USP 797 requires the creation of two physical zones:

Buffer room where the sterile compounding is performed
Anteroom where nonsterile compounding activities occur such as hand washing, storage, and measuring/weighing/mixing of nonsterile substances

The configuration of the buffer room and anteroom is different in low- and medium-risk environments (buffer and anteroom can be in one shared room if separated by a visible line or physical barrier) than in a high-risk environment (buffer and anteroom must be separated by a wall with a door). USP 797 provides specific direction on the cleanliness or purity of the air in the buffer room. Compounding of sterile substances must be done in a laminar airflow workbench or a biological safety cabinet which, in turn, must be located in the buffer room. Detailed guidelines for architectural finishes in the buffer room are also specified and the minimum amount of furniture, equipment, and supplies should be brought into this room. Pharmacy staff must scrub their hands and gown in the anteroom before entering the buffer room.

As an alternative to a clean room, particularly for a smaller facility with minimal compounding, USP 797 specifically allows the use of a mobile isolator chamber (MIC). MICs can take the place of a clean room by providing clean room conditions within a contained workspace. Pharmacy staff access the work area via sealed gloves and do not have to fully gown before they begin work. However, barrier isolators should still be located in an environment that is as clean and sterile as possible. When compared with a clean room, they may be more economical to install and operate, require less space, and are less costly to maintain. back to top

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Trendline Print (PDF)

Rethinking the Traditional Intensive Care Unit

BACKGROUND

Many hospitals feel that they never have enough intensive care beds and are constantly pressured to expand existing units or create new units. Historically, intensive care units (ICUs) have provided intensive observation and treatment of patients in unstable condition. Because of the high-tech requirements and highly skilled staff, these units are expensive to build and operate. Insufficient intensive care beds also affects the ED, as high-acuity patients waiting to be admitted backup in the ED when the ICUs are full.

CURRENT TREND

Healthcare organizations are redesigning ICUs to better monitor and care for patients, are improving nurse-staffing ratios, and are hiring specialists, known as intensivists. Remote patient management of critically-ill patients is being successfully implemented in a number of hospitals around the United States in response to shortages in nursing staff and intensivists, and the desire to improve the quality of care and patient outcomes. Remote or virtual ICU monitoring centers can monitor multiple ICUs at once from a remote location with real-time “telepresence,” including the review of clinical documentation and medical images, the monitoring of vital signs, and the use of digital stethoscopes and high-quality video cameras. Use of a remote patient management system, such as the eICU® solution patented by VISICU, allows scarce nursing and physician intensivist staff to be more effectively leveraged 24-7 and can provide quicker identification of problems, faster intervention, improved outcomes, and lower operational costs. This system also allows rural hospitals improved access to intensive care resources.

OPTIONS

With changing reimbursement, a shortage of specially-trained personnel, advances in technology, and limited access to capital dollars for facility renovation or expansion, hospitals are looking for alternatives to the traditional ICUs. Some options may include the following:

Acuity-adaptable patient rooms allow for staffing and equipment to be more readily adjusted to meet the needs of patients, thereby eliminating unnecessary transfers, potential overstaffing, and excessive treatment based on ICU protocols. Instead, critically ill patients, regardless of their location within the hospital, would be monitored remotely using the eICU concept.
Chest pain centers, typically located in or proximate to the emergency department, can provide extended observation and evaluation of patients complaining of chest pain and can eliminate unnecessary admissions to a cardiac ICU
Chronic ventilator units provide care for ventilator-dependent patients who have been traditionally cared for in expensive ICUs because of the absence of alternative facilities.
Day recovery centers are alternatives to cardiac ICUs for patients requiring cardiac monitoring for 12 to 24 hours following invasive cardiac procedures
Extended recovery room hours accommodate surgical patients who require 12 to 24 hours of intensive post-operative observation prior to being transferred to an inpatient nursing unit or discharged

CONCLUSION

These alternatives can help head off the unfortunate situation in which a healthcare organization builds additional ICU beds only to find that it is unable to staff them due to recruiting difficulties in a tight job market. back to top

Cynthia Hayward, AIA, ACHA, FAAHC

Principal

Hayward & Associates LLC

chayward@hayward-assoc.com

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Technology

RFID Gaining Momentum in Hospitals

OVERVIEW

Hospitals are increasingly using radiofrequency identification (RFID) technology to optimize equipment and supply management, improve patient flow, streamline hospital operations, and improve patient safety. RFID uses radio waves to automatically identify and track the movement of items or people. The basic hardware includes an RFID tag (consisting of a microchip with an antenna) and a reader or receiver. RFID can be either passive or active. With passive RFID, the small RFID tags must be within a one-meter range of a reader ― making it a good choice for inventory management. Active RFID tags transmit at higher power levels and have ranges of 30 feet with a battery life of up to 10 years. Transmitting a constant signal, they can provide continuous tracking of people or items that move frequently and over large distances throughout the hospital.

ACTIVE RFID IN HOSPITALS

Some uses of active RFID in hospitals include the following:

Track patients. A disposable active RFID tag can be attached to a patient’s wristband to track him/her from admission through discharge. The tag’s signal, combined with location analysis software and the hospital’s information system, provides real-time information to locate patients, alert nursing staff, and assemble metrics for management (e.g., length of stay, occupancy).
Find equipment and supplies. Instead of spending time looking for equipment and supplies, nurses can simply glance at a computer screen. Nursing staff can also be automatically alerted when equipment is transported to a non-clinical area.
Streamline operational processes. By tracking patients and staff, work processes can be documented and data collected to facilitate operations reengineering.
Improve patient safety. Patient tracking can alert clinical staff when a patient leaves a specific area or whether the patient is in the correct procedure room in addition to improving the communication and coordination among caregivers.

These and other benefits of active RFID enhance the efficiency of caregivers while improving patient safety and the quality of care. back to top

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Rule-of-Thumb

Emergency Department Capacity and Preliminary Space Need

Component	Capacity	Department Gross Square Feet (DGSF)	Comments

Emergency/ Urgent Care Area:
Poor Performance	1,100 to 1,200 annual visits per treatment bay	550 to 650 DGSF per treatment bay	Assumes average treatment room/bay turnaround time of 180 minutes and that 50% of peak daily visits occur during busiest 8-hour shift.
Average Performance	1,300 to 1,600 annual visits per treatment bay	550 to 650 DGSF per treatment bay	Assumes average treatment room/bay turnaround time of 150 minutes and that 50% of peak daily visits occur during busiest 8-hour shift.
Peak Performance	1,700 to 1,900 annual visits per treatment bay	550 to 650 DGSF per treatment bay	Assumes average treatment room/bay turnaround time of 120 minutes and that 50% of peak daily visits occur during busiest 8-hour shift.
Nonurgent Care/Fast Track Area:	1,700 to 2,400 annual visits per treatment bay	400 to 500 DGSF per treatment bay	Assumes average treatment room/bay turnaround time of 60 to 90 minutes and that 75% of peak daily visits occur during busiest 8-hour shift.

Note: DGSF represents the "footprint" of a department or functional area and includes the net square feet of the individual rooms as well as the space occupied by internal circulation corridors, walls/partition, and minor utility shafts; DGSF excludes common areas such as shared public corridors and lobbies, elevator banks, stairwells, major mechanical spaces, and the space occupied by the building's exterior wall.

Source: SpaceMed Guide (Second Edition).