Flexibility, Focus on Future are Keys to Healthcare Design Success

Flexibility, Focus on Future are Keys to Healthcare Design Success

By Kelly M. Pyrek

Although construction of healthcare facilities in the late 1990s increased, hospital revenues and inpatient census declined. The reason, according to California architect Donald McKahan, AIA, has everything to do with the fact that hospitals and clinics are "retooling their facilities as the healthcare industry reinvents itself for the future," he writes in the white paper Healthcare Facilities: Current Trends and Future Forecasts.¹ It is possible to have growth without profits, but it is a trend most administrators obviously hope is a short-term one. In the meantime, healthcare design professionals are riding a similar roller coaster.

Data from surveys conducted by the American Institute of Architecture (AIA) chronicles the up-and-down nature of healthcare construction. In 2002, 26 percent of architectural firms serving the healthcare industry generated the majority of their billings from healthcare projects. This is down from the 1997 firm survey that revealed 30.2 percent of healthcare design firms received the majority of their billings from healthcare projects.

In 2002, the AIA firm survey found that 12.2 percent of billings across the entire architecture industry were from healthcare projects. This is up from 12 percent of billings in 1997.

Healthy profit margins frequently are built with lumber and nails, and the inextricable relationship between clinical technology and healthcare design and construction has its origins in the 1940s and 1950s, experts say, when the growth of services was triggered by the needs of the post-war populace. Every decade since has deepened the co-dependency one component has on the other. In the 1960s and 1970s, the rapidly evolving breakthroughs in medical technologies -- including transplantation, microsurgery and synthetic antibiotics -- were matched by new communications and materials management infrastructures. In the 1980s, clinical advances were consistently made, although U.S. healthcare underwent significant cost-cutting. The 1990s were characterized by reducing the length of stay, moving to the outpatient setting and creating spaces that supported patient-centered care.

"Based on the exponential changes in clinical services, operational trends and new technologies, it is not surprising that many facilities, hailed as state of the art 20 or even 10 years ago, are becoming functionally obsolete long before their physical life is spent," according to a group of Canadian architects.² Healthcare facilities of the past were static, institutional and forbidding places; facilities of the future, they say, are fluid, friendly, and above all, flexible and able to accommodate clinical, technological and people-driven changes to spatial needs. They identify the following trends:

• Continued clinical advances that encourage mobility and minimally invasive surgeries
• Increased acuity of inpatient and outpatients
• Expansion of outpatient clinics and the creation of ambulatory "themes" through selective clustering
• Increased recognition of the family/caregiver's contribution to the healing process
• Gradual acceptance of the benefits of non-traditional modes of therapy
• Increased awareness on the part of healthcare consumers and a taste for the latest in diagnostic techniques and treatments, as well as increased point-of-care diagnostic treatment
• Increased clinical research integrated into patient-care settings
• Increased emphasis on patient education in the healthcare facility setting

Healthcare architects today are criticizing outdated design solutions that "compromised our abilities to respond to changes in how we work and deliver services; too many solid walls that limit our ability to connect visually and acoustically with our patients and colleagues, floor plans that are too narrow to allow for appropriate relationships; floor-to-floor heights that limit our ability to maintain current standards for air handling and electrical systems and to accommodate some of the new pieces of high-tech equipment; and building sites that do not permit the expansion and renewal that is essential for today's and tomorrow's healthcare system."²

"Design mistakes that have been made in the past include not making the pre-operative area and the actual patient area not private enough, not large enough and not inviting enough," says Richard L. Miller, FAIA, principal in charge and president of Tennessee-based Earl Swensson Associates, Inc. "As procedures have become more complicated, with more surgical and nursing staff involved, we started with some rooms that, in retrospect, are inadequate. They might have worked for that time and place, but as the center evolves, these rooms don't. Everyone wants to squeeze space as much as possible because space is costly, but there are some minimums you shouldn't go below."

Miller is a proponent of keeping future growth needs at the forefront of the design. "If in the original plans there was no prior thought as to how a facility could be expanded, it can be quite a challenge to meet new demands for capacity," he says. "Whenever you build, you should think about future expansion. A client of ours in Nashville started with four operating rooms; we knew there was potential to grow to eight ORs so we actually preplanned and did a drawing that reflects how the facility could expand in the future. It was a concept that rippled through pre-op, holding, recovery and support areas."

In keeping with this kind of imperative, healthcare design and construction professionals are challenged to "anticipate, to the greatest degree, where changes are most likely to occur and to consider flexibility throughout all stages of the planning, design, construction and post-occupancy phases to ensure that the ultimate goals of client satisfaction, desirable clinical outcomes, efficient work environment and effective use of limited capital dollars are achieved."²

Healthcare design professionals say that when carefully crafted, a facility strategic plan can become "a dynamic solution that solves your current demands, responds to your changing needs and welcomes the future for the next generation."² This plan also must be fluid enough to anticipate changes in technology, demographics, care-delivery models and new opportunities. Having said that, Chefurka² asks, "Do we manage our way through changing service demands or design our way out of them?" and "Do current trends create opportunities or barriers?" Maintaining flexibility, design experts say, should be the common thread throughout the entire design and construction process.

Master planning is the first and one of the most important steps toward realization of a healthcare facility. Painted in broad brushstrokes, the master plan addresses space requirements such as the adequacy of the site to accommodate the anticipated use; its location relative to the patient population the facility will serve; and its size relative to its ability to respond to internal and external factors that trigger the need for expansion.

Chefurka says that when in the master planning phase, the following should be considered:

• Will the facility be a single building or a healthcare campus?
• Does the facility accommodate important support services such as materials management and inventory, laundry or food services?
• Does the facility accommodate service growth and change, such as including imaging services at a future date or going "paperless" and requiring less storage space?
• Does the facility support vertical or horizontal expansion within current zoning considerations?
• How will the facility construction be phased to accommodate municipal site services (utilities) that affect project infrastructure?

Keeping important trends, socio-economic factors and clinical imperatives in mind when crafting a master plan for a healthcare facility is essential, says Miller, who is co-author of Hospital and Healthcare Facility Design. One such trend "he says" is how outpatient facilities have influenced inpatient modalities.

"Many of the outpatient modes have influenced what we do with inpatient design," Miller adds. "The No. 1 thing we set out to do, with the client's approval, is de-institutionalize the experience for healthcare consumers. Patient-centered care -- a trend that started in OB/GYN departments and practices prior to outpatient care -- had a strong influence on what has rippled through the entire healthcare industry. Being patient-friendly and family-friendly is vital to the design planning process. If you can create the healing atmosphere from the moment the patient approaches the facility and continue it inside and out, you have come a long way toward improving the wellness and recovery process."

In his book, Miller defines and outlines this paradigm shift from a provider-centered system to a consumer-centered system that has had a profound effect on "shaping the emerging social and technological climate in which architects, healthcare and hospital administrators and planners, healthcare providers and public policy makers must collaborate to create healthcare facilities with quality, cost-effectiveness and flexibility sufficient to carry them through the 21st century."³

"Outpatient facilities are at the forefront of this paradigm shift, but really, evolution in reimbursement started the revolution -- giving a patient some choice in where and how he or she received healthcare -- has changed everything," Miller says. "There are healthcare facilities being designed these days that are so far from the old model that you would never think you are in a medical facility."

One example of how outpatient facilities are changing healthcare design principles is in the way high volumes of patient traffic and rapid operating room turnaround times are handled.

"The patient's movement through the healthcare facility is important to the design process. Architects try to avoid cross traffic. The patient enters the facility, is taken logically to the next step and prepped, brought in for the procedure and brought back for recovery and post-operative care. We refer to it as a pure loop, where you begin and end but you have never crossed your own path. This kind of loop also maximizes staffing efficiency, since patients come in the front door, cycle through the surgery center and are served by the same caregiver."

It seems that patients and clinicians are looking for the same kind of convenience, another big factor in healthcare design of today.

"In an inpatient setting, surgery is within the depths of the hospital," says H. Ralph Hawkins, president of the Academy of Architecture for Health within the American Institute of Architecture and a principal of Texas-based design firm HKS Incorporated. "Many newer healthcare facilities, both inpatient and outpatient, are trying to provide a public 'storefront' of sorts for better accessibility. This is a concept that was created within the outpatient setting and borrowed by inpatient hospitals. Both surgeons and patients like not having to go through the bowels of a large institution."

The storefront concept is part of the consumer-oriented approach to healthcare, Hawkins says, adding that creativity of design is more important that ever.

"Healthcare consumers and healthcare providers alike are more aware of the storefront value of these facilities," Hawkins states. "Healthcare providers want healthcare consumers to remember and like their facilities. In a way, healthcare facilities are destination-oriented; if healthcare consumers say, 'What a cool-looking building,' they will remember it, so much so that architecture almost has become a brand image for surgery centers."

Having to correct the sins of their design fathers, many healthcare facilities are being forced to renovate and retrofit their existing buildings, Miller says. "Not only are we seeing a lot of surgery centers having to renovate, we also see retrofitting in existing hospitals to create a surgery center within the hospital. That can be a significant challenge. Just by virtue of where these places are located within a hospital it can be very difficult to create an inviting, easy-access entry, and how do you combat the obviously more institutional atmosphere that surrounds the new outpatient center? You can do it design-wise with finish and color but what I have often heard argued is you can't take the hospital mentality out of the hospital-affiliated outpatient surgery center. That is an operational issue, not a design issue, but they do go hand in hand."

That's why many facilities are choosing to build ambulatory care campuses, preferring to build horizontally and outward, instead of vertically and inward. Miller says the concept of a healthcare village addresses the need for proximity, convenience and resource sharing. Hybrid facilities tend to be a key component of these campuses.

"You can have outpatient projects that happen to have inpatient beds; and then you can have outpatient projects that have everything but beds," Miller explains. "They both serve many of the same functions. We have a project in Collierville, Tenn. that is a hospital with 50 beds but it is really an outpatient setting. It combines physician office space, inpatient beds and all the outpatient features that touch what is almost an outdoor mall, so the whole experience unfolds for the healthcare consumer. Another project of ours began as a physician's office space but didn't have surgery; it incorporated cancer treatment, radiation and chemotherapy; it had rehab, holistic medicine, women-specific services and operating suites, so here's a 320,000-square-foot building that doesn't have one bed in it. Each project serves the same purpose, and you could add beds to the one that doesn't have them. The healthcare village is an interesting phenomenon because these campuses combine so many modalities in a like environment. It's perfect for physicians because everything is adjacent to where they work and it's convenient for the caregiver, patient and family."

Robert Marasco, president of medical design firm Marasco & Associates and partner in the ASC Group, points to a client, Idaho Falls Surgical Hospital, as an example of how healthcare campuses can include interesting hybrid facilities.

"This project sandwiched a surgical hospital between the most dominant OB/GYN and orthopedic practice in town," Marasco explains. "Patients can move into the hospital through these practices or they can enter the hospital directly. This kind of project often is one of the first steps in creating a healthcare village. The facility opened a few months ago and when it becomes successful we will put up a medical office building next to the surgical hospital; the people who fill that building are small practices that can use the hospital's imaging, physical therapy and surgical departments, so it becomes an entity that grows together. The next step in the healthcare village is creating commercial spaces in those buildings, such as having maternity clothing outlets near the OB/GYN, or health food outlets and medical spas."

Marasco says land and space issues are critical to the creation of healthcare villages. "The Idaho Falls project could probably sit on four acres of land but instead we have 20 acres. I think docs short themselves because they don't realize they are going to be successful; they build on lots that are not adequate in size. Usually you have four square feet of land per square foot of building; the land costs are significant but it is often cheaper to buy more land and let it sit there than it is to move your building because you don't have space to expand."

Despite the gradual growth of medical villages that could swallow up the surgery center's visibility, ASCs still serve as the engine for many healthcare campuses.

"It took about 15 years for 3,000 surgery centers to come into their own," Marasco says. "I think this will double in the next three years. But we need to be as active in the market as possible in the next three years because I think it is going to taper off gradually. But the reasons for surgery centers' popularity will still exist. Physicians want to practice medicine but they can't generate enough income off of their professional fees to be able to pay for additional expenses such as skyrocketing malpractice insurance. So the smart guys say, 'I have to find a way to take every action in medicine and make it pay off for me.' But every time they show up at the hospital, all of the money goes to the hospital. The easiest thing to do to combat that right now is start a surgery center. I don't know if there are more projects out there but our problem is not finding leads to build these centers, it's ranking those leads so we do the best projects. The opportunities are vast."

One important trend is the growth of surgical hospitals from surgery centers, a risk that should be calculated carefully, Marasco cautions.

"Surgical hospitals should be designed in a linear fashion," Marasco adds. "I think a surgical hospital probably should not start out as a surgical hospital. It should start as a surgery center. But a surgery center should be designed to hospital standards. I'd like to see them be in business a few years, make a profit and make sure their systems work, and then become a surgical hospital by adding beds. Whenever you do a surgery center the biggest mystery is making sure the caseloads physicians say they say will bring to the center actually show up. If you open the facility as a phase-one surgery center and the cases come, then it is very easy to determine how much more caseload you will get if you convert to a surgical hospital. If the cases don't come, you stay as a surgery center. It does cost more money to design an ambulatory surgery center to a surgical hospital standard, and there are some different criteria -- spaces you need to have or not have or areas that need to be bigger -- but it pays off."

That payoff can come from anticipating caseload growth and the resulting need for more space that in turn leads to higher profits.

"If my expenses in a surgery center or surgical hospital are rent, equipment, staff and supplies, the reality is, the smallest of those four items is rent or the cost of the building, so it doesn't hurt you much to build bigger," Marasco says. "I am not saying to build a bunch of ORs you don't need; but build the facility a little bigger so it can move to surgical hospital status down the road. That's probably money very well spent. There's no question surgical hospitals are more expensive and more risky because you have to deal with beds. But the rewards can be greater, too."