THE DYNAMIC NATURE OF MODERN HEALTHCARE ENVIRONMENTS
For many, the modern hospital stands as symbol of technological mastery, order, and control in the face of the chaos that illness brings to the social fabric. When one lifts the hood on the modern hospital, however, one is struck by just how much flux and change is taking place within the halls of these central social institutions.
Hospitals are experiencing a wave of construction and renovation unseen since the construction boom following WWII. Hospital construction activity was measured to be around $15 billion in 2003,1 driven largely by decaying and obsolete facilities, changing patient demographics, seismic codes, and technological advances.
With approximately 4,800 registered U.S. hospitals,2 this translates to approximately $3 million per hospital in construction and renovation each fiscal year. To put this into perspective, with revenue per hospital averaging $70 million per year,3 renovation costs equal almost 4% of yearly hospital revenue.
Another way to understand the impact is to look at hospital bed availability. Each year the total hospital square footage offline due to construction is equivalent to 215 entire hospitals. The scope and scale of these changes is extensive and continues to grow each year.
Faced with such extensive change, hospital design is moving away from traditional “brick and mortar” construction paradigms. The move towards long-term facilities planning, modularity, and design around a technology-enhanced workflow are all part of a series of design trends reshaping the architecture of hospitals and the larger healthcare built environment.
THREE PRIMARY DRIVERS FOR CHANGE
New technologies, increasing focus on patient/family-centered spaces, and the competitive pressure for services all are forcing hospitals to adjust their physical environments accordingly.
New technologies. Wireless patient record keeping and increasingly sophisticated imaging technologies are driving the need for space allocation dedicated to tech support and IT systems.As new technologies enter the hospital, work flows are influenced. This, in turn, affects planning and space allocations.
Patient/Family Centered Space. Patients and families are increasingly demanding a variety of amenities to make their hospital experience more “home-like,” such as single family rooms and comfortable, hotel-like waiting areas.
Competitive Pressures. Both the pressure to keep up with the competition and the desire to improve efficiencies are forcing hospitals to realign their facilities in the face of increasing fiscal pressures, demographics, and patient needs.
These changes in hospital facilities are only expected to increase over time. The need for hospitals to adapt to these various drivers is accelerating. This need creates increasingly dynamic conditions in the hospital built environment.
SCOPE AND SCALE
The changes taking place in hospital facilities are ubiquitous and extensive. Over 2/3 of U.S. hospitals are in some state of transition. Of these, most of the hospitals under renovation are larger—over 240,000 s.f. with 250 or more beds.
Project costs vary widely for a given fiscal year, ranging from $110,000 to $100,000,000. Most hospitals are regularly allocating funds to facilities upgrades and improvements as newtechnologies, shifting Full Time Equivalents (FTEs), or changing patient needs put pressure on the extant facilities.
In California in particular, State Bill SB 1533, focused on seismic retrofitting, has led to major expansions of hospital renovation and construction. Besides upgrading for seismic retrofitting, many states are mandating changes in hospitals due to outdated materials and higher standards for healthcare excellence.
TECHNOLOGY DRIVES REGULAR CHANGE
Technology is one of the primary drivers of facility change. In particular, the increasingly prominent role of complex imaging and diagnostic modeling technologies is demanding an increase in infrastructure support. As these technologies become more sophisticated, new rooms, data cabling, and conduits must be created in accord with changes to hospital space planning tied to new workflow patterns. In addition, workflow patterns based on the traditional “tower and pancake” model of hospital design with multiple floors dedicated to different specialties often does not mesh with the increasingly interconnected and interdisciplinary nature of technology driven healthcare.
Because of these shifts in technology, and the obsolescence of facilities, hospitals are making changes due to technology on a regular basis.
Roughly 70% of respondents4 reported having had to make changes over five times per year in their facilities due to outdated facilities not meeting the needs of new technologies. New and improved wireless services, IT services, diagnostics and imaging, electronic medical records, MRI facilities, and catheter labs all require major renovation of space to accommodate new work flows, or provide room functionality not available in original configurations. A Facilities Manager at a major California Hospital in the Bay Area commented, “We continually upgrade our CTs and MRIs to the latest technology. There is always some renovation/construction work required.”5 The bottom line for many facilities managers is that “patients always need the newest, latest, greatest care. Technology has to keep up with every aspect of patient care.”6
The number of these renovations over time illustrates the dynamic nature of the hospital environment driven by technological change. Consistent renovations and regular expenditures due to obsolescence in technology and other factors drive these changes in a way that make the interior environments of modern day hospitals one of significant fluidity.
PATIENT/FAMILY CENTERED SPACE
As the hospital amenities competition heats up with increasing demand from patients and families for comfort and control, hospitals are forced to adjust their rooms to accommodate family needs more directly. The overall thrust for many facilities managers in this regard is “making the buildings more patient friendly.
[We are] looking for ways to facilitate expansion of community services.”7
One of the major changes in alignment with this trend is the creation of single rooms (Figure 2). The demand for single rooms with accoutrements found in hotel suites is a growing concern for many facilities managers, who feel that they have to “improve the patient and family experience”8 by creating facilities that match the needs of the users.
COMPETITIVE PRESSURES – CHANGING SERVICES
Patient and family demand for particular services, changing service offerings, and the creations of focus factories (centers of excellence) are key factors driving the needs of facilities renovation.
Patient demand for specialty services ranging from cardiac cath labs to fertility clinics are increasingly driving hospitals to make changes in facilities to keep up with competitive demands. Like any other industry in a consumer driven marketplace, hospitals are under increasing pressure, as informed patients demand better accommodations and excellence in treatment. This is forcing many hospitals to become more responsive to remain competitive in an increasingly consumer driven marketplace.
In addition to expanding service offerings, hospitals are also faced with pressures to improve operating efficiencies. The imperatives of HMOs and other business performance criteria are forcing hospitals to consider both the expansion of profitable and consumer marketable services, but also the cutting and scaling back of all forms of redundant and inefficient facilities and procedures. To quote one facility manager, “The goal is to figure out how to do more with less, and do it better.”9
FLEXIBILITY AND CHANGE AS NORM
Future trends point to increased changes, with over 68% of respondents10 believing that the extent of renovation will increase over the next five years (Figure 3). With increased volume and a desire to improve patient satisfaction, coupled with changing technologies and the desire to meet patient demands, the future of hospitals will continue to require change. Technology, patient demands, and the fluctuation of particular service offerings will all drive a more dynamic and fluid internal environment that must continually adapt to change and novelty in the healthcare world of the future.
CURRENT AND FUTURE DESIGN TRENDS
Because of the increasingly fluid technology and consumer driven dynamics of the health care environment discussed above, there is an opportunity to move away from traditional “brick and mortar” hospital construction towards more flexible environments where change can be accommodated and addressed rapidly andefficiently. Several implications for planning and design arise from these trends:
1. The creation of core centers of excellence. These “Focus Factories” for specialty services like cardiac or orthopedics, which draw attention to hospitals just as university departments are known for their particular areas of specialization. This allows a hospital to create attractive and marketable service packages that are recognized and sought by increasingly sophisticated healthcare consumers.
2. Hospital planning will be increasingly focused on adaptation. Hospitals will shift from short term, reactive response to change to incorporating change into long term planning and design. Hospitals will use more thorough front end strategic and scenario planning as a key feature in hospital design to plan and adapt to changes over time.
3. Design around workflow and current care models. Hospitals increasingly will follow design models like airports where a core hub with all centralized services provides a terminal area from which people will be directed towards specialized needs. Instead of traditional “towers” with departments, hospitals
will follow an information model with hubs, nodes, and communicative corridors as the core design elements.
4. Pervasive and distributed computing. Hospitals of the future will be highly wired with digital patient record keeping, wireless diagnostic devices, and other forms of information and collaboration enhancing tools to enhance productivity, and track and adjust to shifting conditions rapidly. Like El Camino Hospital in California, one of the nation’s most wired health care environments, workflow and hospital facilities will need
to be adjusted to the role digital technology plays in “ABC” (Activity Based Computing) as more diagnostic, treatment, and recovery is supported by digital devices and work processes.
5. Hospitals will increasingly be modular. Generalized rooms will be fitted with core elements that can be easily swapped out to address patient or staff requirements as demographic trends and patient needs shift over time. Instead of building a fixed design, fluid environments will be created which can adapt to change as needed.
6. Integrative medicine integrated in workflow and space planning. As demand for integrative medicine grows in modern healthcare, the integration of wellness centers into the overall hospital environment and work plan will need to be accommodated. The creation of a global integrative care model will affect how spaces are planned, shifting from rigid departmental floors to a more holistic approach to total care.
The modern hospital built environment is one of constant change, forced to respond to external drivers putting significant pressure on outmoded facilities. Adapting these changes requires continual renovations by facilities managers who must make choices to address a variety of new pressures.
In order to respond to the increasing pace of technological change and competitive pressure, hospitals will have to embrace new design and construction paradigms that support flexibility and adaptability.
A focus on thoughtful planning and research is a core element to success in this process. The more forethought, research, and analysis, both qualitative and quantitative, that goes into the planning process, the higher the likelihood of success.