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Healthcare Facility Planning Tools and Guidelines Volume 2, Number 2 |
Spring 2009
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In This Issue
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Developing a Bed Expansion Plan When There is a Deficit of Private Rooms Hospitals Are Adding Complementary and Alternative Services Planning a More "Virtual" Center of Excellence |
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Feature Print (PDF) |
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Developing a Bed Expansion Plan When There is a Deficit of Private Rooms BACKGROUND
PH has experienced fluctuation in demand for inpatient beds over the past several decades. Beginning in 1980, with pressures from payers, both the rate of admission and length of stay dropped resulting in a rapid decline in inpatient utilization over the subsequent decade. The downward trend in inpatient workloads began moderating in the mid-1990s as a backlash to managed care. In a complete reversal of the trends of the early 1990s, PH experienced increased demand for inpatient care over the past few years. However, with the recent downturn in the economy, PH leadership is unsure of how to proceed. Although some bed replacement and expansion was deemed necessary by all members of the planning team, the CFO was concerned about spending significant capital dollars given current economic conditions. PH executives were also not in agreement regarding the extent of the required expansion ― some wanted to plan for 100 percent private rooms while others were concerned that significant expansion would require additional staff at a time when budgets were tight and recruiting was difficult. Others were concerned about losing admissions to competitor hospitals who had more contemporary patient accommodations. Declining length of stay was also a concern. However, everyone agreed that the current use rate (admissions per 1,000 population) would most likely remain constant. They also agreed that the county’s updated population forecast for 2020 was reasonable given that it was much lower than previous estimates. PLANNING APPROACH The PH executive team was not interested in projecting the need for an absolute number of beds at some future date. Instead, PH wanted to identify the range of beds required based on the most optimistic versus pessimistic view of future market conditions ― particularly since decisions to expand or replace their inpatient facilities would start a chain reaction of events and involve a long-range commitment of dollars, staff time, and operational disruption. All members of the planning team agreed that a sensitivity analysis was needed to model the impact of different planning assumptions on future bed need and to evaluate the magnitude of renovation or construction. They also wanted to look at the relationship between high-bed need and low-bed need scenarios and the resulting number of private patient rooms that could be available. As shown in the table on the following page, different scenarios were modeled based on varying market share, length of stay, and occupancy rate assumptions with the use rate and projected service area population held constant as follows:
The target occupancy rate was also an issue for PH. The hospital typically used 80 percent occupancy as a target. However, PH realized that organizations with all private patient rooms are re-evaluating this target. Given the high cost of construction and planning uncertainties, PH’s CFO was willing to accept the risk of not accommodating all demand during peak periods to avoid having vacant patient rooms during average census periods. The Director of Planning noted that, statistically, a hospital with all private patient rooms should be able to maintain a higher occupancy level than one with a large number of semiprivate or multiple-bed rooms. On the other hand, targeting a higher occupancy level would not be practical for PH if it maintained its current high percentage of semiprivate patient rooms. PH decided to use a target of 85 percent occupancy assuming that it needed to increase the number of private patient rooms regardless. The PH leadership team had the following observations regarding the 2020 bed need projections:
ANALYSIS The graph below displays the high-bed need and low-bed need scenarios projected through 2020 with varying occupancy assumptions. The hospital’s existing licensed capacity of 250 beds is also shown along with the existing number of patient rooms ― regardless of whether some were originally designed to accommodate two patients.
Low-bed need scenario. Since this facility was originally designed with a total of 200 patient rooms (150 privates and 50 semiprivates), in the low-bed need scenario PH could essentially use all the patient rooms as privates during the average daily census (192 patients) while retaining a limited number of semiprivate rooms to accommodate peak census periods and maintain its current licensure. No expansion would be necessary through 2020 unless PH desired to upgrade or replace some of the existing patient rooms ― enlarge the patient rooms and provide wheelchair accessible toilet/shower rooms and additional amenities. High-bed scenario. Bed expansion would definitely be required in the high-bed scenario to accommodate the 2020 bed need. If the high-bed need scenario comes to fruition, PH considered the following possible bed expansion strategies:
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CONCLUSION The PH executive team recognized that even though the low-bed need scenario resulted in less beds than were currently licensed, PH was effectively only using 220 beds rather than 250. All of the 60 semiprivate patient rooms in the two oldest nursing units were too small to accommodate two patients given the amount of equipment and technology used today to deliver inpatient care. They decided that even in the low-bed need scenario, they still needed to replace at least 30 beds. This would result in a total of 230 patient rooms that could all be used as privates if the low-bed need scenario occurs ― assuming that the resulting number of beds per nursing unit did not compromise efficient staffing patterns. The PH executive team agreed on the goal of having enough patient rooms to accommodate the 2020 projected average daily census of 245 patients (high-bed scenario). The existing semiprivate patient rooms would be maintained and deployed during high census periods if the high bed need scenario evolves. Ultimately, PH developed a plan to construct 72 new beds, all in private rooms. The remaining 20 semiprivate patient rooms would be maintained to accommodate peak census periods. Depending on the future bed scenario that evolves, the two oldest nursing units could be redeployed for same-day/observation patients, although the beds could still be used as overflow inpatient beds at some point if necessary. With the existing 150 private patient rooms, 30 converted private rooms (existing semiprivates), 72 new private patient rooms, and 20 remaining semiprivate patient rooms, PH could expand it licensure to 292 beds to accommodate the high bed need scenario for 2020 if needed. If this scenario does not come to fruition, the oldest nursing units could be permanently decommissioned for an alternative use and all the remaining semiprivate patient rooms could be converted for single-patient use. This would result in a total of 242 private patient rooms. Like many hospitals, PH was challenged with planning a staged conversion of semiprivate patient rooms to privates over time. However, they hoped to plan for additional flexibility that could offset forecasting inaccuracies. If the low-bed need scenario plays out, then some of the existing semiprivate patient rooms could be used for single occupancy. On the other hand, if the high-bed need scenario comes to fruition, then PH would need to deploy some of the rooms as semiprivates during peak census periods. back to top Cynthia Hayward, AIA, ACHA, FAAHC Principal Hayward & Associates LLC chayward@hayward-assoc.com |
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In the News |
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Hospitals Are Adding Complementary and Alternative Services OVERVIEW
CAM is not based solely on traditional Western allopathic medical teachings and may include acupuncture, homeopathy, herbal medicine, and massage therapy, along with diet and lifestyle changes. The focus is to treat the whole person ― body, mind, and spirit. SURVEY FINDINGS Other survey findings include:
ENTIRE ARTICLE More information on the survey can be found at the Health Forum Online Store by following the link for Data Products and selecting CAM Study. back to top |
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Trendline Print (PDF) |
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Planning a More "Virtual" Center of Excellence BACKGROUND
From a facility planning perspective, decisions to develop specific Centers of Excellence are complicated. Historically, these centers were envisioned as freestanding facilities with the name prominently displayed on the building’s facade. Before high-speed Internet/Intranet connections, this concept was promoted to improve collaboration and communication among the healthcare providers as well as to enhance customer service. CURRENT TREND Healthcare organizations are increasingly looking for more cost-effective ways to achieve a similar result while spending fewer capital dollars. To accomplish this, they are focusing on the specific elements that give customers the perception of a “center” to identify which functional components and services will need to be physically adjacent versus virtual and connected electronically. Unless the center is being constructed as a freestanding facility on a new site, some services could be located within existing space while others are in a new addition. The trade-offs between the cost (initial capital cost and ongoing operational costs) of achieving physical adjacency versus settling for less-then-perfect convenience for the customer need to be reviewed and weighed carefully. The potential for increased revenue, reimbursement, and the demands of donors, partners, or investors may also impact the requirements of the physical design. Unfortunately, physicians often have difficulty imagining a “center” that is not an imposing edifice or at least a freestanding building. For example, a Heart Center may be developed on an existing hospital campus by creating a dedicated patient entrance that leads directly to the Heart Center reception desk and intake area. An adjacent cardiac resource center for patients and family members may provide educational materials on heart disease and private carrels for viewing videos or accessing computer resources. A contiguous conference room may also be provided for group education on various aspects of heart disease and the lobby may be used for periodic health promotion and assessment activities as well as for fund raising. However, all other Heart Center components may be located within an existing outpatient facility or within the hospital and accessed via an elevator or a short walk down an adjacent corridor ― including cardiologist and cardiac surgeon offices, non-invasive cardiac diagnostics, cardiac catheterization lab, cardiac rehabilitation, and other related services. CONCLUSION From the patients’ perspective, once they arrive at a well-identified entrance and are greeted by a friendly and competent receptionist, they are generally oblivious to where they are treated as long as signage is effective and they are not asked to walk a great distance. An elevator ride with a short walk to space in an existing building is not considered a hardship even though the physician leaders may feel that new construction is mandatory. back to top Cynthia Hayward, AIA, ACHA, FAAHC Principal Hayward & Associates LLC chayward@hayward-assoc.com |
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Technology |
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The Future of Surgery is Here Now OVERVIEW The past two decades have witnessed a revolutionary transition in surgical technique and technology. Traditionally, surgeries had been performed in the open manner, in which large incisions were required for the surgeon to plainly observe and manipulate the surgical field. These incisions inevitably created significant patient trauma ― substantial pain and suffering, extended recovery time, prolonged pain management, and elevated costs. Approximately 20 years ago, surgeons began practicing a new approach to performing surgery, an approach that came to be known as minimally invasive surgery, or MIS. During this era, tiny cameras in instruments called endoscopes or laparoscopes were introduced. These visual and surgical aids could be inserted in the patient's body through small ports. Although revolutionary in its positive effect on patient trauma and recovery times, MIS encountered significant technical drawbacks. The surgeon operated using a standard 2-D monitor instead of looking at his or her hands. The resulting image flattened the natural depth of field, and the fixed-wrist instruments limited his/her dexterity. The lack of 3-D visualization of the operative field, the poor ergonomic design and reduced control were major roadblocks to further progress. As a result, this type of MIS turned out to be suitable for a narrow range of surgical procedures. In the late 1990s, another evolutionary stage in the development of surgical technique was achieved with the application of robotics to surgical technology. At the forefront of this new era, Intuitive Surgical introduced the da Vinci Surgical System® which is now used at medical centers throughout the U.S. to perform complex surgical procedures including general, cardiac, thoracic, gynecologic, and urologic procedures. It is the only commercially available technology that can provide the surgeon with the intuitive control, range of motion, fine tissue manipulation capability and 3-D visualization characteristic of open surgery, while simultaneously allowing the surgeon to work through tiny incisions typical of minimally invasive surgery. HOW IT WORKS With the Da Vinci Surgical System, the surgeon performs surgery with a surgical arm unit that positions and maneuvers detachable surgical EndoWrist instruments. These pencil-sized instruments (with tiny, computer-enhanced mechanical wrists) are designed to provide the dexterity of the surgeon's forearm and wrist at the operative site through entry ports less than one centimeter. This enables the surgeon to enter the body through keyhole incisions to perform surgery. One port allows access for the endoscope, a tiny camera that is attached to a fiber-optic cable. The other ports provide access for surgical tools. Instead of the surgeon holding the tools, the robots wrists do ― bending back and forth, side to side, and rotating in a full circle ― thereby providing greater range of motion than humanly possible. The wrists of the robot mimic the motions made by the surgeon, who sits at a console remote from the patient. The surgeon peers through an eyepiece that provides high-definition, full-color, magnified, 3-D images of the surgical site provided by the endoscope. The physician moves his or her hands, which are attached to manipulation controls and the robot follows along. An important element of this technology is that the built in computer enhances the surgeon's hand movement and renders it more precise with less tremors ― an important element in delicate surgery. KEY OPERATING ROOM COMPONENTS The da Vinci Surgical System consists of an ergonomically designed surgeon’s console, a patient-side cart with four interactive robotic arms, the high-performance InSite Vision System and proprietary EndoWrist instruments. The four components can be accommodated in a standard operating room that is designed for major surgical procedures (e.g., 600 net square feet).
TELEMEDICINE WILL BE NEXT The da Vinci Surgical System ― with patient on the operating room table and the surgeon console physically separated ― can theoretically be used to operate over long distances. Although this capability is not currently the primary focus of Intuit Surgical it will certainly be the next evolution of this exciting technology. back to top Additional information can be found at www.davincisurgery.com |
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Rule-of-Thumb |
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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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Copyright ©2009 SpaceMed. All rights reserved. |
Prudent Hospital (PH)
was originally designed to accommodate 250 licensed beds of which only 60
percent are in private patient rooms (150 beds). The remaining 100 beds are
located in semiprivate rooms resulting is a total of 200 actual rooms (150
privates and 50 semiprivates). The current average daily census is 205
inpatients resulting in an average occupancy of 82 percent. The occupancy
rate, however, is misleading because PH rarely places more than one patient
per room in the two oldest nursing units ― each with 30 semiprivate rooms.
Because of concerns with patient privacy, infection control and medical
errors, along with undersized semiprivate patient rooms, PH leadership
wanted to develop a bed expansion and replacement plan to address inpatient
demand through the year 2020.
In response to patient
demand, hospitals are integrating complementary and alternative medicine
services with the conventional services they typically provide according to
a survey released last fall by Health Forum, the American Hospital
Association subsidiary that publishes Hospitals and Health Networks.
According to the survey, 37 percent of responding hospitals indicated they
offer one or more complementary and alternative medicine (CAM) therapies, up
from 26.5 percent in 2005.
For several decades,
healthcare organizations have been developing Centers of Excellence (CoE) to
better compete for market share, research dollars, philanthropy, and scarce
subspecialists in specific programs. Promoting a specific program within the
healthcare organization’s broader portfolio of services helps to attract the
critical mass and resources required to make it successful. Centers of
Excellence are commonly developed for cardiac care, cancer treatment,
neurosciences, orthopedics, pediatrics, and women's health. Various other
clinical programs and specialties may also be candidates for a Center of
Excellence.
