A surprising number of hospitals are in the midst of facilities planning and expansion activities. This is somewhat surprising given the economic times and the recent unfolding of political/regulatory changes. Perhaps this is a good sign; that the economy is improving and that a backlog of capital projects are moving forward as planning for the new fee-for-value era is better understood.
CFA has been working with several hospitals and their architectural firms on planning and developing new cardiovascular or expanded invasive interventional facilities or relocating and/or expanding outpatient heart and vascular centers into new or renovated and expanded space. This is an opportunity most programs will get only once or twice in their lifetimes. CFA’s cardiovascular expertise is being utilized to provide clinical and operational advice to the clients, culminating in detailed work load projections that will determine the number, size, location and critical adjacencies of all relevant departments and functions. In the course of this work, a number of key factors have surfaced that bear notice to anyone contemplating new or expanded outpatient cardiovascular services. These issues have important economic and operational consequences and need to be carefully and thoroughly considered. We share some of our perspective on these issues below:
- The CFA team recommends that when initiating a comprehensive facility planning effort, you should begin the process with a significant focus on what will be your organization’s underlying philosophy of care. Two philosophical issues that will have real, practical implications for future space are:
- Initiation of a patient-centered care approach, where, to the extent feasible, tests and procedures are brought to the patient, not the reverse (thus questioning the optimal size of an outpatient clinic exam room); and,
- Movement from a “physician-centric” care approach to a more “team-based” care approach (particularly for chronic patients such as CHF).
- Workload projections that look five, ten or more years into the future and are based on historical and current data can be problematic and are impacted by multiple, interdependent variables. As an example, for large clinic exam rooms, some, but not all of these factors include:
- Number of physicians by specialty/subspecialty; clinic volumes, work hours/days, payment methodology, staffing of outlying clinics, teaching/research assignments, practice “style” and other factors.
- Number and type of outpatient clinics by specialty/subspecialty programming (on campus or off campus)
- Assumptions about room “turns” and “dwell times;” the average number of patients that can be seen (or that are expected to be seen) in a room over a given period of time.
- Clinic design definitely has an impact on patient flow, throughput and overall efficiency.
- New and evolving technology is a key factor that must be considered. For example, the initiation of hybrid space in the traditional cath lab facility (now evolving into the “interventional platform space”) is a technologic, economic and frankly, a political decision. In our client hospitals, advanced CV imaging technologies such as cardiac CT and MR are the subject of serious debate about potential duplication, procedural volumes, and co-location in an integrated heart and vascular center.
- Seriously consider incorporating soft spaces that can readily be reconfigured without major cost or shelled-in space for future expansion. Although many hospitals will not have the luxury of allocating shelled-in space for future use, such as for hybrid procedure rooms, cardiac CT/MR, cardiac cath/EP/Vascular labs and the like, it is well worth considering. Be careful not to underestimate the future space need; although certain advancing technology tends to get smaller over time, support space needs tend to grow.
- Carefully plan for the movement of invasive/interventional cardiovascular procedure rooms (cath/EP/vascular labs) into available new space. Sequence the purchase of new or renovation of older equipment to coincide with new space. Work hard to not be afraid of considering moving older equipment into newer space; it is less expensive than you may think and the useful life of certain technology can be extended through nominal cost upgrades.
- Reconsider traditional cardiac rehab functions and spaces. Under fee-for-value, rehab will take on increasingly recognized importance, particularly in decreasing length of stay and preventing readmissions, among other important clinical and financial benefits.
- Do not forget nor minimize the importance of meeting rooms, educational and training spaces that are as adjacent to your functional working spaces as possible. These have traditionally been given lower priority over clinical spaces, but they are steadily taking on an increasingly important role going into the future.
- Design must consider increased efficiency and cost when developing any new spaces.
- Lastly, remember that when asked, everyone will want more space; only some will be able to clinically and financially justify more space. The challenge is separating the former from the latter and developing a project planning priority list that balances the competing dynamics of your cardiovascular enterprise, the potential space available and the capital budget for the project.
Designing new or renovating existing facilities is a complex and important task. Considering the risks inherent in making poor choices, a deliberate and systematic approach and considering the use of outside experts can be a prudent way to go – shameless plug aside.
As always, CFA invites your comments, suggestions and questions.