Big ideas for small facilities

Amy Douma
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Critical access hospitals offer lessons in space-saving design for buildings of all sizes

The phrase “health care innovation” often evokes images of technology advancements, breakthrough research and perhaps sprawling urban, academic medical campuses. Few immediately associate this phrase with the rural health care systems and critical access hospitals (CAHs) providing much-needed services to the nation’s most remote regions.

However, rural facilities are fertile ground for innovative, field-leading ideas. Facing difficult financial realities and chronic staff shortages have forced many rural hospitals to rethink traditional delivery models simply to continue providing care to the populations they serve.

Rural systems also possess several advantages that enable them to generate out-of-the-box ideas, including staff members who are cross-trained to support multiple departments, enabling them to think beyond the traditional silos that can hinder large-scale innovation.

Many CAH staff members also have inspiring, can-do attitudes, and their motivation to preserve a strong local health care presence in their communities can lead to creative ideas.

Emphasis on efficiency

Given the financial challenges faced by rural facilities, it is not surprising that many recent innovations inspired by these providers aim to leverage both space and staff as efficiently as possible.

The universal platform, a collection of centralized, flexible spaces that can shape-shift as needed to support multiple departments, provides one example. Most universal platforms consist of relatively small rooms that can serve functions as diverse as surgery preparation and recovery, emergency treatment, observation and even infusion. Sharing spaces between the surgery and emergency departments works especially well given their complementary peak times in patient volumes — surgery functions are typically busy early in the day, while emergency department (ED) volumes tend to increase in the evening hours.

Designing a space that can switch departments as needed — as well as support a host of other functions — reduces the overall space required for a facility while increasing its flexibility to meet future demands.

CentraCare Health in central Minnesota has implemented this concept in several recent CAHs. For its replacement facility in Long Prairie, Minn., the universal platform primarily serves surgery, emergency and observation functions.

Spaces within this platform can flex between uses easily throughout the day depending on patient volume and need. Staff are cross-trained for all functions, resulting in a solution that minimizes both space and staff, and the platform’s location across from the inpatient unit ensures excellent visibility.

The benefits of this approach have been both immediate and long-term. Compared to traditional department-based planning, the universal platform saved over $1 million in construction costs at the Long Prairie facility alone. Additional savings were achieved in furniture and equipment costs, as duplication between departments was minimized.

The most significant benefit, however, is the long-term flexibility provided by this planning concept. Because spaces within the universal platform can easily shift function, this approach accommodates volume swings and service line shifts without the need for costly renovation.

Another innovative space-sharing strategy was introduced by Samaritan North Lincoln Hospital, a CAH in the resort community of Lincoln City, Ore. When designing its replacement facility, hospital leadership was originally interested in incorporating a universal platform concept, especially given their widely fluctuating ED volumes between the busy summer tourist season and the remainder of the year. However, Oregon codes precluded sharing the surgery prep/recovery rooms with any other functions, so Samaritan developed unique sharing solutions.

To accommodate surges in ED volume, Samaritan located several rooms that perform outpatient functions during the day (e.g., surgery consults and blood draws) adjacent to the ED so they can flex into that department in the evening. Each flex room is furnished with a recliner appropriate to its daytime function as well as Level IV and Level V ED cases.

To provide additional surge space, the ED also can expand into several diagnostic imaging rooms that serve dual-energy X-ray absorptiometry (DEXA) and ultrasound functions during the day. The imaging equipment within these rooms can be rolled out or protected in place, and dual room entries enable the spaces to convert seamlessly to onstage and offstage ED treatment spaces.

Samaritan’s other unique space-sharing strategies include a flexible dining space that doubles as lobby seating and expands into an adjacent conference room when needed. Additionally, exterior seating and two staff break rooms serve as dining overflow, so dedicated dining space could be minimized. Similar flexibility is provided in the inpatient unit, where all patient rooms are sized to intensive care unit (ICU) standards and cross-corridor doors enable two ICU/acute-care rooms to serve postpartum functions when demand in the birthing unit exceeds the capacity of the facility’s two labor, delivery, recovery and postpartum rooms.

This level of flexibility designed throughout the Samaritan North Lincoln facility significantly reduced square footage and its associated cost by eliminating duplicated space. Additionally, this flexibility will serve Samaritan well in the future as patient volumes change and community needs evolve.

Implications for other facilities

While it may be tempting to directly duplicate these innovative approaches in other facilities, design teams should first understand the broader context in which these ideas were developed, because it contributed to their ultimate success. In each of these examples, an organization had the unique opportunity to rethink its traditional care delivery practices in preparation for a major building construction project.

Operational efficiency was essential to maintain long-term financial health, but it was one of many goals. For an idea to gain traction with hospital leadership and staff, it needed to support all three components of the Institute for Healthcare Improvement’s Triple Aim: improving health outcomes and enhancing human experience as well as reducing costs. Had these ideas been proposed simply as cost-cutting measures imposed by leadership, successful implementation would have been much more challenging.

Also, achieving buy-in for new ideas and processes typically requires sustained engagement of many project stakeholders. For both the CentraCare and Samaritan projects, health care system leadership set the tone and encouraged all parties to push the boundaries of traditional care delivery. Community members and patient advisory boards were consulted regarding their perceptions and care priorities. Numerous front-line staff members were involved throughout the process to build a sense of ownership, identifying improvement opportunities, generating solutions and driving final implementation.

While this may sound complicated, it has proven to be an effective way to encourage innovative thinking and manage change in complex organizations. To organize this process, the design teams used the overall framework described below and several Lean-inspired tools to uncover new ideas, focus conversations and guide the implementation process. They include:

Engage. For both the CentraCare and Samaritan projects, innovation began with a deep understanding of current conditions and challenges. Project stakeholders identified existing processes that were working well — and those that weren’t — from the perspective of patients, family members and caregivers. This knowledge enabled each organization’s leadership and staff to develop cost-saving ideas that were meaningful to their specific situations and to solve problems holistically versus starting with a potential solution. Useful tools for this phase included “Gemba walks” and value-stream maps.

Focus. Next, the design teams worked with hospital leaders and staff to identify consistent themes that surfaced during the “engage” portion of the process — especially those tied to operational inefficiency or patient satisfaction — and define priorities for improvement. This clarified the root sources of problems and ensured that the final solution addressed them holistically. For example, Samaritan uncovered numerous challenges with wayfinding in its existing facility; while this clearly is a concern for patient satisfaction, staff also noted that it impacted clinical efficiency because it contributed to numerous appointment delays.

Explore. The groups then brainstormed potential solutions and researched best practices from other facilities facing similar challenges. During this phase, universal platforms and other space-sharing strategies were explored in depth, and multiple departments were brought together to strategize systemwide solutions.

Samaritan, for example, identified several key moves that would solve multiple challenges simultaneously. To mitigate wayfinding issues and improve patient experience, the design team worked with staff to bring services to the patient, resulting in several rooms designated for outpatient services adjacent to the main entry. The group then configured these rooms to flex into ED overflow space in the evening, resolving the problem of volume variability described earlier.

Investigate the details. Before moving to implementation, the design teams worked with hospital leadership and staff to investigate the details of implementation. Mockups of proposed solutions, such as universal platform rooms, were studied in depth to ensure that they met the needs of all functions using the space. Additionally, staff members identified potential process changes and training needed to achieve the desired operational outcomes.

Apply and test. The final step was applying and testing the solution. While construction was necessary for full implementation, the team identified several process adjustments that could be implemented within the existing facility so they would become part of daily practice before the new space was complete. This prework enabled staff to make a relatively seamless transition to the new care approach following construction. The solution was evaluated at regular intervals (usually every three months) once staff had the opportunity to test its functionality. This ensured that any ongoing challenges were uncovered and addressed, typically through minor process adjustments.

This process requires a commitment of time, but it is a proven method to generate new ideas, encourage positive change and enact operational improvements at a broad scale. As the CentraCare and Samaritan projects demonstrate, the results of this process can be well worth the investment.

Implementation challenges

While the process described above helps build cultural acceptance of new ideas, organizations considering space-sharing innovations may face several additional implementation challenges. For example, health care codes are often written around discrete and definable functions. Concepts like universal platforms, which blur the lines between the traditional hospital departments, can create challenges in achieving and even assessing compliance.

Samaritan North Lincoln Hospital faced this hurdle several times during the design and construction process. While the hospital’s unique space-sharing ideas were reviewed with code authorities early in the design process, only a conceptual approval could be provided at that time. Specific requirements, such as clearly demarcated ED and outpatient paths, required lengthy discussion and iterative plan adjustments to gain regulatory approvals much later in the project’s development.

To avoid unexpected setbacks and changes, organizations considering these types of planning innovations should share their ideas as soon as feasible with code officials to secure buy-in and to open a dialogue regarding implementation options. This allows all parties to understand the reasoning behind the proposed strategies and enables officials to guide project stakeholders to solutions that will meet regulatory intent. Even when these steps are taken, extra financial and schedule contingencies should be considered to accommodate late-stage regulatory changes.

A final implementation challenge involves potential trade-offs between operational flexibility and the experience of patients and families using the space.

Because universal platforms and other shared spaces tend to be centrally located between hospital departments, access to natural light and views can be limited. This is particularly of concern when functions such as observation and infusion, which may require patients to stay for significant lengths of time, are part of the mix.

Similarly, these spaces’ central location can present wayfinding challenges for family members, who may wish to access the cafeteria or other public spaces while waiting. Careful consideration of these needs — in addition to operational efficiency — must be part of the planning process.

Worth the investment

While successful implementation of the space-saving innovations described may pose challenges, many rural organizations have found that their long-term financial and operational benefits are worth the investment.

By adapting these concepts to their own needs and constraints, other facilities of diverse scales and locations may uncover additional ways to leverage resources and inspire innovation within their own organizations.

CentraCare’s new hospital in Long Prairie, Minn., uses a universal care platform to leverage space and control costs.
 

CentraCare’s new hospital in Long Prairie, Minn., uses a universal care platform to leverage space and control costs.