An innovative approach to Healthcare Planning
Written by Miguel Burbano de Lara, AIA, NCARB, and Annie Lilyblade, NCIDQ; LEED AP BD+C
Traditionally, the conversation around optimizing the performance of health systems in the United States has suggested that improvements in the individual patient experience of care, improvements in population-based care, and reduction of costs are “either-or” aims requiring compromise. Indeed, the focus most often has been on improvements in the individual provider experience, including productivity, utilization, and frequency as a way to improve efficiency and reduce costs—often at the expense of the individual patient experience and community health and wellness. The result has been a health care system in crisis, in which one sees overuse of health care resources in some areas and lack of access even to fundamental care in others.
In the United States, the Institute for Healthcare (IHI) developed the Triple Aim http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspxas a response to this crisis and a framework for an approach to optimizing health system performance. It is based on the belief that new designs must be developed to simultaneously pursue three dimensions of health care: improving the individual patient experience of care, including quality and satisfaction; improving the health of patient populations; and reducing the per capita cost of health care. IHI developed a concept design and described five components of a health system that would fulfill the Triple Aim: focus on individuals and families, redesign of primary care services and structures, population health management, cost control platform, and system integration and execution.
Pioneering health care leaders are now changing the traditional conversation—and actively pursuing the Triple Aim—using an innovative approach to planning, architecture and construction to create buildings that support their achievement of all three goals. These solutions are a “win-win-win” for individual patients, communities and health care organizations.
Buildings as Agents of Change
Yes, innovative health care organizations and their integrated teams are demonstrating that the buildings that support delivery of wellness and health care services can be powerful change agents with a significant impact on the safety, quality, access, efficiency and cost of health care. Indeed, buildings are not merely shells to contain a hospital or clinic -- they are tools to support the transformation of the delivery of wellness and health care.
Leaders in the health care field are achieving these changes using an evidence-based design strategy that integrates Lean workflow redesign with Lean facility design, leveraging the power of the electronic health record (EHR). This strategy is supported by digital modeling systems that enable visualization of the design and operational variables (e.g., patient flow and provider/staff workflow), and quantify the effects of various design alternatives on the organization’s objectives for individual patient care, community wellness and operational efficiencies. Using these methodologies and metrics, health care leaders and their facility development partner teams work to refine organizational processes and building designs to resolve the tensions and conflicts among the three aims rather than to compromise any one for the benefit of another.
For example, in the case of an out-patient care clinic in the Midwest U.S., this strategy was used to facilitate a transformational change to a team-based, integrated care model supported by robust EHR Performance metrics have proven the success of this approach, including:
· 17-percent total space reduction in the size of the building, with significant savings in initial construction costs and ongoing operational costs
· 16-percent increase in capacity, from supporting 49 providers to supporting 57 providers
· 76 percent of patients rated their experience as excellent; 21 percent as good
· 50-percent increase in provider recruiting success
· Other health care organizations have applied the lessons learned from this project to further the Triple Aim in their own communities.
Redefining the Individual Patient Experience
St. Charles Health System, Inc., headquartered in Bend, OR, is scheduled to break ground in winter 2013-14 on a new 62,000-sf health care campus in Prineville to replace its existing 60-year-old 90,000-sf facility—significantly reducing its footprint while offering a greater range of patient, family and visitor services. The new health care campus will feature a 10,000-sf primary care and specialty care physician clinic and a 50,000-sf hospital including Emergency Department, 12 inpatient beds, imaging and laboratory services, two surgical suites and a retail pharmacy.
The new campus is a physical manifestation of St. Charles’s organizational transition from a traditional medical model to team-based, integrated patient-centered care model. Implementation of a robust EHR, automated pharmacy management and just-in-time inventory management will support this transition. Moreover, the building is being designed as an integral agent of organizational change.
St. Charles leaders understand that physicians are the engines of all health care organizations, and they need an environment that optimizes their effectiveness. As evidence-based professionals, they also require that the integrated facility delivery team demonstrate that a particular number of points of care—supported by appropriate equipment deployment, staffing ratios and a robust EHR—will optimize their utilization. The solution was also aligned with specific demand forecast models developed in accordance with demographic studies.
The clinic module component has been planned to provide comprehensive patient care within the exam rooms and adjacent diagnostic and treatment spaces—from registration to discharge instructions. Individual physician offices have been eliminated in favor of central collegial work and lounge spaces for the entire patient-care team and adjacent space for extension care givers including nutritionists, social workers and physical therapists. Plans have also eliminated the traditional waiting area in favor of a concierge-style patient greeting desk. The public area includes seating and a cafe that is designed to appeal both to clinic patients and hospital visitors, as well as other members of the community.
Celebrating Community Health and Wellness
As an integrated health care system, CentroMed http://www.centromedsa.com/, envisions itself as “... a leading health care provider and employer recognized for quality customer service, clinical excellence, comprehensive care, and responsiveness to community needs.” El Centro del Barrio, founded in 1973 and doing business as CentroMed since 2001, is a nonprofit Federally Qualified Health Center that offers primary medical and dental care, behavioral health services, nutritional services, and other support services through a network of 21 sites throughout San Antonio and Bexar County, Texas. Well ahead of its time in providing a patient-centered medical home, CentroMed is also committed to “stewardship ... to maximize our human and financial resources for the care of our community, especially medically underserved residents.”
The three-year-old Health & Wellness Center at CentroMed Southside Medical, located in San Antonio, is a synergistic facility that not only offers a full range of health and wellness services, but also serves as a community center. Dedicated in December 2010, the facility comprises two adjacent buildings unified by a landscaped central plaza entered through an open gateway. The 39,000-sf Community Health Center providing medical, dental, Ob/Gyn, pediatric, lab and imaging services, as well as a dialysis center. The 32,200-sf Wellness Center comprises a gymnasium and private women’s fitness center with memberships at lower than market rates and on-site child care. The Wellness Center also has a unique event room that not only serves as a venue for health education classes—it even hosts community events, including weddings. Designed to break down the stereotypical image of a community health center, the center is designed with beautiful, durable materials, including detailed stone and ceramic tile.
Improving Access, Reducing Costs with New Urgent Care Center
Established in 1993, Carson Valley Medical Center (CVMC) http://www.cvmchospital.org/about_us.aspxprovides quality health care to the residents of Carson Valley and surrounding areas of Nevada. A joint partnership of Barton HealthCare System of South Lake Tahoe and Renown Health of Reno, CVMC is a non-profit state accredited critical access hospital with 23 licensed acute care and ICU patient beds; the area’s only 24-hour ED; surgery; diagnostic imaging; laboratory services; and rehabilitation therapy; and eight primary care physician offices/clinics throughout the area, including family medicine and senior care practices.
Based on the results of a community health needs assessment that was completed in spring 2013 http://www.cvmchospital.org/sites/www/Uploads/CVMC_CHNA%202013%20Report.pdf—in which 44 percent of survey respondents identified the cost of health care as a primary concern—CVMC is responding with definitive efforts to control costs of providing health care, such as increasing efficiencies and properly advancing health care technologies. Approximately 24 percent of respondents identified access to care as a key concern, CCVC is responding by establishing urgent care services in the community to offer extended hours and additional providers.
The new 10,000-sf urgent care center is being planned for the north end of Gardnerville, which will address these concerns. Planned as an infill facility, repurposing a portion of an existing 32,000-sf shell, it also has the potential for significant construction cost savings over building a new facility from the ground up.
The integrated delivery team and CVMC leaders are in the process of envisioning how the space can be used to support the care team process using other leading U.S. urgent care and outpatient care centers as models for staffing ratios, integrated care, process and space planning efficiencies. New providers will be recruited specifically for this urgent care facility; the planning process is providing CVMC with information models to illustrate these concepts as clinic leaders talk with prospective members of the new care team.
Resolving Tensions Among the Three Aims to Benefit of All
The common denominator in every successful transformation is understanding, managing and resolving the tensions that are always present. These include the individual patient experience of care versus preventive population health and wellness; an individual provider-based health care environment versus an integrated, team-based, shared-resources model; acute versus ambulatory care; greater patient access and convenience versus a “9-to-5” provider working environment. These types of tension must be managed and resolved -- converted into a win-win-win solution -- otherwise the result will be failure.
The ultimate test for any process change or facility solution is whether it is good for the patient, improves community wellness and improves the vitality and financial results of the health care organization. And the results must be measurable and objective, including time, money, quality and improved outcomes.
In the United States, the national dialogue unfortunately has become negative in terms of the needed change in health care. It has become increasingly necessary and now possible to transform an adversarial health care system into one that embraces the Triple Aim; leading health care organizations are in the process of achieving it.
To drive change forward in our own communities, we must all focus on the health care transformation in our daily lives. Indeed, we must become more vigilant, become more committed, and make more demands: if patients ask their doctors for wellness over treatment; if we ask our representatives in government for community health; if we ask our employers and payers to demand lower costs—then everyone will win.
For over 35 years, Miguel Burbano de Lara, AIA, NCARB, has followed a passion for health care design. Clients and associates recognize his commitment to stay relevant with technology and trends surrounding the health care industry. He has lectured at the Universidad Autonoma de Coahuila, Mexico, South Auckland Health, NZ, and is a frequent presenter at national conferences and meetings, such as AMGA, MGMA, and NACHC.
Burbano de Lara earned a Bachelor of Architecture degree from Texas Tech University, and has since completed over 500 projects. His client list includes Stanford University, University of Arizona, Kaiser Permanente, Sutter Health, Sisters of Mercy Health System, and Catholic Healthcare West, as well as international clients in New Zealand, Australia, and Latin America. He has participated in over 800 medical projects ranging from individual provider suites to large group practices and rural hospitals. He has worked at The Neenan Company since 1999.
A member of the American Institute of Architects (AIA), Burbano de Lara also served as AIA Colorado North Chapter President in 2005. He is also a member of many professional and civic organizations.
To achieve success in an increasingly competitive marketplace, Burbano de Lara strives to create health care facilities that blend the beauty of architectural aesthetics with functionality necessary for superior health care services delivery and sustained business growth. At The Neenan Company, he has focused on Lean theory, design innovation, and accelerated delivery as transformational processes for facility development.
Annie Lilyblade, NCIDQ; LEED AP BD+C, is a medical planner for The Neenan Company. Lilyblade holds a bachelor’s degree in interior design and a master’s degree in sustainability and construction management. She assists with the strategic development of innovative solutions for transformational healthcare facilities. This includes EHR implementation, sustainability, efficiency, flow, resource optimization and best practice compliance. Additionally, she contributes to the environmental design from a functional, ergonomic and hospitality perspective.