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Healthcare Facility Planning Tools and Guidelines

Volume 1, Number 4

Fall 2008

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Planning the Clinical Laboratory of the Future

Healthcare Construction is a High Stakes Game  

Planning Flexible Healthcare Facilities is No Longer Optional 

More Hospitals Are Becoming Unplugged

Oncology Services Capacity and Preliminary Space Need

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Planning the Clinical Laboratory of the Future 

BACKGROUND

The clinical laboratory was historically organized by testing methodology or discipline and the space was subdivided into numerous small rooms reflecting this organization. With the advent of multidisciplinary pieces of equipment, automated technology, robotics, and the demand for rapid results by clinicians, clinical laboratories are being functionally reconfigured by turnaround time as well as testing methodology. Laboratory managers who seek to reorganize clinical testing along these lines often find that the physical facility is a barrier to more efficient operations. Instead of compartmentalized space, contemporary laboratories need open, flexible space that easily accommodates new technology, allows staff to freely work among various pieces of automated, multidisciplinary equipment, and can be eventually converted to a totally automated laboratory.

In the past, the clinical laboratory was typically located on the main floor of the hospital, usually adjacent to the emergency department and surgery suite ― two labor and technology intensive patient treatment areas. This location facilitated the convenient and rapid transport of laboratory specimens and results. With new advances in specimen transport systems, computerized results reporting, and the advent of point-of-care testing, this location for the laboratory is no longer necessary, nor is it advisable to locate it in “prime real estate” when its space is primarily used for specimen processing that does not require face-to-face patient interaction.

Moreover, as hospitals have aggressively formed networks and alliances in response to cost containment and competitive pressures, it became evident that not all hospitals could justify a full-service laboratory, nor was it deemed necessary.

As a result of market dynamics and technological developments, laboratories are being redesigned with more open, flexible space, often located in less-expensive space, but connected to the key patient care areas by a specimen transport system and with computer linkages to point-of-care laboratories.

REORGANIZATION OF THE CLINICAL LABORATORY BY TURNAROUND TIME

The hospital laboratory includes the two main components of clinical pathology and anatomic pathology. A third component ― transfusion services (or the blood bank) ― is responsible for the acquisition, storage, and preparation of blood products for infusion. Historically, these functions were performed next to each other but in distinctly separate areas of a large, central laboratory.

At a minimum, hospitals in the future will have a highly-automated core laboratory on-site providing rapid turnaround time that may be supplemented with point-of-care laboratories at key locations throughout the hospital complex.

Regional reference laboratories (providing testing on specimens with a more lengthy turnaround time) may be developed to take advantage of new technology or specialized expertise. Reference work may be consolidated at a single location or divided between multiple hospitals to fully utilize existing space, staff, and equipment. For example, all microbiology testing may be performed at one hospital and all special chemistry testing at another.  

NEW FACILITY COMPONENTS

Traditionally, the clinical pathology component of the laboratory was organized by disciplines, such as hematology/coagulation, chemistry/urinalysis, immunology/serology, and microbiology/virology, which were physically separated. Instead, the clinical pathology laboratory of the future will be organized into the following facility components:

• Central specimen processing. This area will function as the central receiving, processing, and shipping area for all specimens except histology/cytology. Over time, central specimen processing will become fully computerized. Bar-coded specimens will be received via a pneumatic tube system or by courier and automatically recorded and sorted. In addition, more instrumentation will use whole blood and have expanded menus so the amount of centrifugation and aliquoting (dividing samples) will be reduced. Specimens will be distributed to the automated laboratory or other testing areas from the central specimen processing area.

• Automated laboratory. This is a grouping of highly-automated instrumentation into one section of the clinical laboratory ― centralizing the performance of all the high-volume testing in the disciplines of hematology, chemistry, urinalysis, and coagulation. This configuration allows significantly greater efficiency and faster turnaround time than would be achievable if each of these sections were separately located and staffed. The automated lab performs tests as soon as they arrive in the laboratory so there is no need for a separate “stat” lab when this configuration is deployed. In medium and large hospital-based laboratories, there may be automated instrumentation for processing specimens prior to loading them on the instruments. Preanalytic automation ranges from units that totally automate the processing of specimens to units that only automate some of the processing steps. Because this area will be operational 24 hours per day, the transfusion service or blood bank should be proximate to it. By grouping these services and tests, staff efficiency can be maximized, particularly on the evening and night shifts.

• Manual laboratory. The manual laboratory would generally perform the chemistry, hematology, coagulation, and urinalysis tests that are left over after all of the automation has been centralized. Included in this area would be more hands-on types of instrumentation and procedures, such as osmometry, blood gases, manual differentials, and electrophoresis.

• Microbiology. The microbiology section in a small laboratory will typically perform only bacterial cultures. In a medium or large hospital-based laboratory, mycology, mycobacteria cultures (TB), and parasitology may be added. Mycology and TB can be performed in a separate enclosed negative-pressure room. Parasitology will be needed when working with patients who have been in a geographic location where parasitic infections are common.

• Molecular pathology uses polymerase chain reaction (PCR) methodologies, some of which require separation of operations into two or more rooms and may require specific ventilation requirements, such as negative-pressure. Molecular pathology testing will only be provided in larger laboratories.

• Staff/administrative space. Administrative, educational, and other staff support space should be located at the periphery of the laboratory, separate from testing areas, but still accessible to the staff.

• Point-of-care testing (POCT). As tests requiring immediate turnaround are shifted to the point of care, it is anticipated that hematology and chemistry testing in the main laboratory may be reduced over time. Although point-of-care testing facilities may need counter space for tabletop instruments or to store portable equipment used at the patient’s bedside, most point-of-care testing in the future will be performed with hand-held instruments. However, space is still required within the central laboratory. The laboratory typically oversees the point-of-care-testing program ― training nurses in how to perform the tests, monitoring the quality of the tests, and performing preventive maintenance on the equipment. The laboratory POCT coordinator will need both laboratory bench space and a clerical/computer workstation and file storage to manage the POCT program.

Although automation is evolving relative to histology and cytology, the functional organization of the anatomic pathology component is not expected to change significantly in the near future. A frozen section laboratory should be provided adjacent to the surgical suite for rapid examination of surgical specimens. From the frozen section laboratory, surgical specimens and cytology specimens will be sent to the anatomic pathology area of the laboratory for further analysis. Due to their separate specimen flow and analysis, it is not imperative that the clinical pathology and anatomic pathology components of the laboratory be located proximate to each other. Typically, the morgue is located in a remote area accessible to service vehicles.

SUMMARY

Increased automation of the clinical laboratory and the continuing shift to point-of-care testing with portable or hand-held instruments ― either at the patient’s bedside, emergency department, surgical suite, physician’s office, or other ambulatory care settings ― may reduce the number of laboratory staff required. The remaining staff will focus on quality assurance, quality control, and training. Laboratory managers will assume greater responsibility for cost-effective utilization of laboratory services. Therefore, central, hospital-based laboratories may require less space and a location in “prime” space will not be required. back to top

Cynthia Hayward, AIA, ACHA, FAAHC

Principal

Hayward & Associates LLC

chayward@hayward-assoc.com

I would like to thank Judy A. Lien, principal of the laboratory operations/management consulting firm J. A. Lien & Associates, LLC, for her input. Judy is a past president of the Clinical Laboratory Management Association (CLMA) and has served on its board for the many years.

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In the News

Healthcare Construction is a High Stakes Game

OVERVIEW

Healthcare facilities across the U.S. are finding themselves in the midst of a high stakes game. Aging facilities, rapidly advancing technology, intense competition, and increased consumer demand are among the factors that are driving up the ante for new hospital construction or major renovation. Keeping up involves high risk and cost.

Healthcare facility construction costs are rising at a record pace ― doubling since 2004 ― and some experts estimate the boom will exceed $60 billion annually by 2010. Moreover, the risk is substantial. When healthcare leaders decide to build or renovate their facilities today, they may not admit the first patient for six, seven, or even eight years. The technology to be used to treat patients at that time may not even exist today ― or at least not in the same form. The newly constructed facilities will need to meet the needs of patients for at least another 20 or 30 years. During that time, it is not clear whether there will be many more inpatients due the aging U.S. population or fewer inpatients as patient care continues to shift to the ambulatory care sector requiring many more new outpatient facilities. At the same time, physicians and for-profit companies are trying to beat hospitals to the punch.

ABOUT THE REPORT

Discoveries about healthcare construction trends and capital implications are revealed in the fourth report of the Financing the Future III series led by the Healthcare Financial Management Association (HFMA) in partnership with GE Healthcare Financial Services. Researchers surveyed key industry leaders to identify the trends and issues that are affecting future healthcare construction.

The third Financing the Future series is in many ways the most ambitious. HFMA and GE Healthcare Financial Services have set out to identify key industry trends that affect hospitals’ capital position and their ability to fund important future initiatives. The trends are payment trends, technology spending, unfunded liabilities, and approaches to building new hospitals. For each trend, a report identifies the current state and implications for the future.

SUMMARY OF KEY FINDINGS

The findings in Report 4 show a combination of factors are driving renovation and construction costs for the hospitals of the future including:

• Both the number and size of healthcare construction projects is growing and they are getting more expensive due to the rising cost of oil, growing global demand for materials, and potential labor shortages. In response, hospitals will decrease the design/
  construction execution time and design new facilities that reduce operational costs. Services will continue to be delivered in non-traditional buildings that are less expensive to build.

• Although many healthcare facilities undergo an average of seven or more changes or remodels over their lifetime, many hospitals built before WWII cannot be further retrofitted to meet the needs of increasingly sophisticated technology.

• Larger, single-bed patient rooms are being built to accommodate technology, changing levels of acuity, and to facilitate infection control. Hospitals are finding themselves at a very significant competitive disadvantage if they have a limited number of single-bed rooms while a competitor offers all private rooms.

• However, hospitals too often think only about the cost of construction and not the long-term operational costs and potential revenue. As volumes grow, hospitals need more square feet but they should be looking at the square footage per unit of service. In other service industries, the cost per unit of just about anything where technology plays a role has gone down. But in healthcare, the cost per unit of care keeps going up.

• Before hospitals start building, they should make sure that a new building is the optimal way to solve their capacity problems. A thorough review of the current facilities may uncover additional "virtual capacity." Moreover, the most compelling reason to renovate in lieu of starting over, is that you get beds much sooner ― years before you would get them with new construction.

• Ambulatory facilities are also getting bigger ― 100,000 to 200,000 square feet ― double the typical size five or ten years ago. As a result, ambulatory facilities are being increasingly moved off-campus because of lack of land. Standalone facilities are following retail's lead in providing easy accessibility, convenient wayfinding, and parking near the front door ― features which are hard to provide on a typical hospital campus.

COMPLETE REPORT

The complete Report 4 of the Financing the Future III series is titled "Report 4: Healthcare Construction Trends and Capital Implications" and can be downloaded at HFMA's website.  back to top

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Trendline                                                                                       Print (PDF)

Planning Flexible Healthcare Facilities is No Longer Optional

BACKGROUND

The term flexibility has become somewhat overused today. It is repeated as a mantra among healthcare planners and design architects. By definition it means “adaptable” or “adjustable to change.” In reality, achieving flexibility often requires that physicians and department managers and staff relinquish absolute control over their space and equipment for the greater good of the organization. However, with fluctuating workloads, rapidly changing technology, staff shortages and high turnover, and limited access to capital in today’s dynamic healthcare environment, planning flexible space is no longer an option.

WHY IS FLEXIBILITY IMPORTANT

There are many reasons why healthcare organizations need to provide flexible and adaptable facilities such as:

• The unpredictable healthcare environment with fluctuating demand driven by changing reimbursement, new regulations, and media attention.

• The blending and melding of many diagnostic and treatment modalities with advances in technology.

• Staffing shortages in many specialties that necessitate cross-training and the creation of new job descriptions.

• Electronic information management that eliminates the need for physical proximity.

• Limited access to capital that requires ever more efficient utilization of all resources including staff, equipment, and space.

DIFFERENT WAYS OF ACHIEVING FLEXIBILITY

Facilities should be planned to optimize current utilization as well as provide flexible space that can be adapted over time. Some ways to achieve flexibility include:

Planning multi-use or shared facility components enables a healthcare organization to use their space efficiently and balance workload peaks and valleys. Examples of multi-use spaces include:

• Acuity-adaptable or “universal” patient rooms that can be adapted for most levels of acuity by altering staffing levels and equipment; this concept can reduce costly patient transfers during an increasingly short length of stay, provide improved continuity of care, and reduce medical errors.

• Time-share clinic space where physicians lease space ― patient reception/intake area, exam rooms, offices, and support space ― by the day of week as needed thus reducing their fixed costs.

• Multi-use procedure rooms that can accommodate various procedures as needed using different types of portable equipment such as EKG and ultrasound.

• Alternating space use by shift such as using an adjacent occupational medicine clinic or same-day medical procedure unit for treating emergency department (ED) “fast track” patients during the evening and night shift, or holding ED patients in the surgery suite recovery area during the evening (or overnight) for observation, or while waiting for an inpatient bed to become available.

• Co-locating selected procedure rooms so that they can share the same patient reception/intake, prep, recovery, and support space ― for example, various imaging modalities, invasive cardiology and angiography, and endoscopy and surgery.

Planning flexible space that can be adapted over time to accommodate shifts in program focus and fluctuating utilization can reduce long-tern renovation costs. This includes space that can be easily adapted for a different functional use by switching out equipment, adding a second bed, or reassigning offices and workstations to another department. In addition to the acuity-adaptable patient room mentioned above, other examples of adaptable spaces include:

• Planning a flexible diagnostic and treatment center with a central patient reception/intake, prep, and recovery area, shared staff facilities, and a mix of large and small procedure rooms where equipment can be changed and upgraded as needed; this is in contrast to the traditional approach of planning dispersed and fragmented “departments” (e.g., radiology, CT, nuclear medicine, cardiology, ultrasound).

• Providing flexible customer service space using a “one-stop shopping” concept to accommodate admitting/registration, financial counseling, cashiering, scheduling, and other similar services that require face-to-face customer interaction; with flexible offices/cubicles (and cross-trained staff), services can be adapted to the customers’ needs over time.

• Planning a generic administrative office suite to be used by various administrative and support staff who do not require face-to-face customer contact. Space can be reassigned in response to organizational changes, thus eliminating department “turf” issues and improving overall space utilization.

Unbundling selected services ― rather than embedding everything into the hospital structure ― can not only reduce an organization’s initial capital investment, but can facilitate future space reallocation, contraction, and expansion, as workloads, staffing, and operational processes change over time. Some examples include:

• Relocating routine, high-volume outpatient services in separate facilities (on-campus or off-campus) with dedicated parking and convenient access. Examples include primary care clinics, selected high-volume outpatient services, or recurring or chronic outpatient services such as rehabilitation, chemotherapy, and dialysis. 

• Consolidating building support services into a separate service building ― creating space for supply, processing, and distribution functions that is less expensive to construct and renovate as operational systems, technology, and work processes change.

• Relocating administrative offices for staff who are not involved in direct patient care outside the hospital (on-site or off-site) in less expensive and adaptable “office building” space.

Leasing space (versus buying or building) when appropriate allows an organization to limit its capital investment and long-term risk. This may include leasing space off-site for administrative offices and new or expanding outpatient programs. Some healthcare organization may choose to lease space such as hotel conference facilities or a school auditorium for periodic inservice or community education in lieu of constructing an education center on the hospital campus. Interior systems furniture and other building elements may also be leased by making an arrangement with a manufacturer to take stewardship over the product’s life, and putting it together, refreshing it, and recycling it for a reasonable fee. Some healthcare organizations also keep up with changes in technology by leasing imaging equipment or paying based on its use rather than buying the equipment outright.

Building a flexible infrastructure with long-span joists and interstitial space provides a cost-effective way to adapt to ongoing changes over the life of a building. Embedding everything in the building so the pipes and wires are inside the walls, floors, and ceiling, makes it almost impossible to reconfigure any space without major construction. In the future, hospitals may be built more like shopping centers, with a huge superstructure and interiors that can come and go at will, resulting in an adaptable tool for delivering health care. back to top

Cynthia Hayward, AIA, ACHA, FAAHC

Principal

Hayward & Associates LLC

chayward@hayward-assoc.com

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Technology

More Hospitals Are Becoming Unplugged

OVERVIEW

More hospitals are offering wireless networks than ever before according to a recent article in Healthcare IT News. The primary reason is that clinicians and patients expect anywhere, anytime access to the Internet.

FLORIDA HOSPITAL

Florida Hospital in Orlando ― the largest Protestant health system in the country with 16,000 staff members and more than 2,000 beds ― has already installed a wireless network in three of its seven hospitals. It is in the process of assessing costs and timelines to deploy wireless networks at the rest of its hospitals. Like many other hospitals around the country, Florida Hospital is encountering complaints about spotty cell phone access. As clinicians and others add more applications to their smart phones, the complaints multiply.

According to Todd Frantz, Florida Hospital's associate chief technology officer, they installed a MobileAccess Universal Wireless Network, provided by MobileAccess ― based in Vienna, Virginia ― because it was modular and could grow over time. While Frantz did not identify the exact cost, he indicated that it was expensive and estimates a cost of $1 per square foot. "It's extremely difficult to imagine a return on investment," he said. "It's like air conditioning." Frantz expects that hospitals everywhere will have to convert to wireless facilities. "It's not a matter of if, it's when," he said. 

RECENT REPORT CITES GROWTH

A recent report published by the New York based market research firm Kalorama Information also cites increased demand for wireless in hospitals. The report titled "Wireless in Healthcare 2008 (The Market for Bluetooth, RFID, Zigbee, UWB WWAN, WMAN, WLAN, and Other Technologies)" suggests that the compound annual growth of wireless sales in healthcare will jump from 22.9 percent to 29.5 percent, raising sales from $2.7 billion to $9.6 billion in five years. Sales of wireless devices in healthcare have grown about 23 percent annually since 2005 and will continue to rise. In 2003, 25 percent of U.S. hospitals had wireless which is projected to be between 80 and 90 percent in 2010. Hospitals will be earmarking large portions of their future budgets for wireless development.

OTHER HOSPITALS

The Indianapolis-based Clarian Health Partners is two years into a five-year plan for wireless networking and already has 100 percent coverage in two of its facilities and plans to add the same wall-to-wall, floor-to-ceiling antenna coverage in its remaining four hospitals. "The future of healthcare is mobile," said Edwin Simcox, director of enterprise technology planning for Clarian. "It is not fixed-assets IT." He also views wireless as expensive but said that they studied ROI in detail and were able to justify it on a cost basis. They believe that putting in a single antenna system drives down operational costs in maintaining that antenna system.

Children's Hospital of Philadelphia also has a wireless network project underway with a cost of $2.5 to $3.0 million. "The ROI is almost immeasurable when you start throwing safety and patient care into the equation" says Wil Ankerstjerne, program manager of mobility, architecture, and design.

COMPLETE ARTICLE

The complete article titled "Hospitals Unplugged" by Bernie Monegain was published online on July 1, 2008 in Healthcare IT News

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Rule-of-Thumb

Oncology Services Capacity and Preliminary Space Need

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).                                                   

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