Hits: 0
Identifying Facility Needs and Establishing Priorities
WITH AN UNDERSTANDING of your current situation, future market strategy and projected demand, and potential operations improvement opportunities and technology investments, current and future facility needs can be identified and priorities established. The first step is to determine your space needs by location on a department (or service line) basis so that you know the magnitude of current and future space shortages. Other facility deficiencies can then be identified, summarized, and prioritized. Key questions include the following: How well do we orient our customers as they arrive on the campus and circulate through our facilities? What is the workload capacity of our current facilities? Do we have enough space to support our current and projected number of licensed and staffed beds, procedure rooms, equipment, staff, and other required functions? Is our space organized and configured appropriately? (click for project help)
UNDERSTANDING THE SPACE PLANNING PROCESS
Space planning typically requires varying levels of detail at different points in the facility planning process. During the facility master planning stage, a broad-brush approach is used to assess the magnitude of current and future space shortages. Using each department’s footprint, a comparison is made between the current space allocation, the current space need (based on existing services, workload, equipment, staffing, and so on), and the future space need (based on program growth, new services, and anticipated operational and technology changes). The resulting preliminary space projections are used to develop facility reconfiguration options, site plans, and department block diagrams as part of the facility master plan. The planning horizon should correspond to the workload forecasts discussed in chapter 3. For the purposes of facility master planning, the space requirements of individual departments are estimated in the aggregate department gross square feet (DGSF), which differs from the detailed, room-by-room space programming in net square feet (NSF) as described in chapter 8. Detailed, room-by-room space programming is generally undertaken after specific projects have been defined as an outcome of the facility master plan.Its approach to preliminary space planning depends on the organization’s objectives, immediate issues, and corporate culture. The broad-brush approach is used to assess the overall scope of space deficiencies. Detailed, room-by-room space programming is not routinely performed at the facility master planning stage because it entails a tremendous amount of staff time and energy that is not appropriate for all departments, particularly those whose facilities are not an issue and whose status quo is assumed for the near future. In some cases, a more focused approach may be appropriate for one or more departments or service lines, and hospital leaders may fast track the detailed space programming process during facility master planning. Examples may include situations in which a competitive threat requires a shortened planning or design schedule, when code noncompliances must be rectified immediately, or when major pieces of equipment require urgent replacement. In these cases, a decision may be made to overlap the more detailed operational and space programming process for selected departments with the less detailed space planning assessment for all other departments during the facility master planning phase.
TOOLS AND TECHNIQUES At the onset of the facility master planning process, a preliminary list of all nursing units, departments, and functional areas should be assembled that corresponds to the institution’s formal organizational structure or cost center listing. Specific tools and techniques are discussed in the following section(Identifying Facility Needs and Establishing Priorities)
Focused Data Collection, Interviewing, and SurveyingMany facility planning consultants use standardized questionnaires to collect baseline data from department managers and medical directors. One questionnaire is typically used for nursing units (focused on licensed beds), another for clinical services where patients are treated in the department (focused on workload data and equipment), and another for all other support services that do not provide direct patient care (focused on staffing and processes). Baseline data are collected regarding the current scope of services, staffing and scheduling patterns, major equipment units, and workload. Surveys also solicit the perceptions of the department manager or medical director regarding current space deficiencies; workload trends; equipment suitability; and other anticipated changes in services, patient mix, processes, and technology. Focused interviews may then be conducted to assess the ability of the department or service line to accommodate the workload forecasts and operational and technological changes identified by the planning team, as described in chapters 3 and 4. A survey of the department’s current space by an outside consultant or third party provides an objective assessment of the adequacy of current space allocation, quality of the space, equipment and procedure room use, and other facility Using Benchmarks, Rules of Thumb, and Best PracticesHealthcare leaders frequently seek out industry benchmarks, rules of thumb, and best practices at other organizations around the country for validation. The healthcare sector uses different types of benchmarks, including those for assessing market demand (admissions per 1,000 population), financial performance (average cost per adjusted discharge), and labor productivity (full-time equivalents per occupied bed). For facility planning purposes, the most common types of benchmarks are those used to assess the following: Ability of the facilities to accommodate the current workload, such as the annual workload per treatment space Adequacy of overall space in a department to support the number of treatment spaces, such as the total DGSF per procedure room Space productivity, such as the annual procedures per DGSF Space efficiency, such as net-to-gross space ratios
Some examples of how benchmarks may be used to develop preliminary space estimates include the following (Hayward 2015): A surgery suite with 65 percent outpatient cases has 12 operating rooms (ORs) but accommodates only 9,600 annual cases (800 annual cases per OR); using a benchmark of 1,000 annual cases per OR, it would not need any additional ORs to accommodate the five-year growth projection of 12,000 annual cases. A dedicated outpatient surgery suite with six ORs currently has 15,000 DGSF (2,500 DGSF per OR), which is inadequate; using a benchmark of 3,000 DGSF per OR, hospital leadership determines that it requires 18,000 DGSF (an additional 3,000 DGSF).Information regarding best practices in the healthcare sector, where the cost-effectiveness and improved quality outcomes have been substantiated relative to different operational models, can be found in many online sources.(Identifying Facility Needs and Establishing Priorities)
Incremental Need ApproachAt this stage of the space planning process, common practice is to use an incremental need approach (as opposed to the zero-based budget approach employed during the detailed functional and space programming process). With the incremental need approach, space is added or subtracted from the current space allocation to reflect specific space deficiencies and surpluses in an individual department. For example, if a respiratory therapy department is currently assigned 4,300 DGSF and has two vacant offices, then planners can subtract approximately 300 DGSF from the current space allocation to arrive at the current space need of 4,000 DGSF. If at the same time this department has no temporary storage space for equipment that has been cleaned and is being held for disposition, then an estimated 100 DGSF would be added back into the current space allocation, resulting in a revised current space need of 4,100 DGSF.These simple calculations are sufficient for use in preliminary space planning, where the goal is to understand the magnitude of the space deficiencies by major functional category of space. The subsequent development of a detailed, room-by-room space program may result in a slightly smaller or larger space estimate for an individual department.Scenario Analysis and ModelingThe effect of alternate workload and service configuration scenarios on space need is frequently predicted by developing appropriate assumptions and creating a computerized model or simple spreadsheet. For example, neonatal intensive care units (NICUs) are increasingly designed using either the single-family room (SFR) concept, semiprivate rooms to accommodate two infants, or a combination of both. Open-bay designs are primarily deployed where the constraints of existing space do not permit the other two options. To compare the space requirements of the SFR, semiprivate room, and open-bay facility configuration concepts, a space planning model was developed using common support-space assumptions while varying the patient care space. The total DGSF per bed for different sizes of NICUs was also evaluated. As shown in exhibit 5.1, for a smaller NICU with 12 beds, the semiprivate room and open-bay designs require about the same DGSF and the SFR unit requires about 7 percent more space. As the number of total beds increases, the differential between the SFR and open-bay concepts narrows. For a 24-bed NICU, the SFR layout requires 8 percent more space than semiprivate rooms do and only 5 percent more space than the open bays. The SFR concept requires 9 percent more space than the semiprivate room and 4 percent more space than the open-bay concept for a 36-bed NICU.imagesGuidelines for the minimum clear floor area required for each open bay have increased substantially in the past decade, which reduces the variance between the DGSF per bed in the open-bay design when compared with the SFR and semiprivate room options. Also, in this analysis, the open-bay concept provides additional sleeping rooms because recumbent sleeping facilities for parents are not bedside, as in the SFRs and semiprivate rooms.(Identifying Facility Needs and Establishing Priorities)
When the DGSF per bed is reviewed in this example, the economies of scale of a larger unit far outweigh differences in facility configuration concept. NICUs with only SFRs range from 544 DGSF per bed for a 12-bed unit and decrease to 465 DGSF per bed for a 36-bed unit. Likewise, a unit with semiprivate rooms requires 507 DGSF per bed for a 12-bed unit, which decreases to 428 DGSF per bed for a 36-bed unit. The space required for a traditional open-bay NICU with 12 beds calculates to 509 DGSF per bed, which decreases to 445 DGSF per bed for a 36-bed unit. Healthcare leadership should also note that the net-to-gross conversion factor alone—assumed to be 1.50 in this example—represents one-third of the total DGSF per bed in such a way that a more efficient layout could mitigate differences between the facility configuration concept and the number of NICU beds.It should be noted that as the number of NICU beds decreases further (i.e., fewer than 12 beds), the DGSF per bed increases substantially because of the minimum sizes required for support spaces. For example, a six-bed NICU, using the space planning model described in this analysis, would require more than 700 DGSF per bed.
EVALUATING FACILITY CAPACITYAn analysis of facility capacity for clinical services involves identifying current workload volumes and major treatment spaces and then applying industry benchmarks and rules of thumb. Evaluating the capacity of inpatient nursing units, however, is much more complicated if the organization was originally designed with a large number of multiple-bed patient rooms or has taken beds out of service at various points in time.Even with adequate facility capacity, many healthcare organizations are limited in their weekly hours of operation because of the availability of physician, technical, and support staff. Shortages might result from scheduling difficulties, a tight job market, or regulatory and union issues with cross-training staff, for example. This scarcity is also true for inpatient nursing units—such as ICUs—where beds may be closed because of the inability to recruit nurses to staff them.Bed CapacityAny capacity assessment should begin with an inventory and analysis of the inpatient nursing units, as described in chapter 2 and shown in exhibit 5.2. Inpatient nursing units are modular in design and consist of a number of patient rooms that typically share centralized support and administrative space. They vary in the number and type of patient rooms (private vs. multibed), the configuration of the contiguous toilet and bathing facilities, and the total DGSF used to support the specific number of beds.images(Identifying Facility Needs and Establishing Priorities)
As mentioned in chapter 2, the design capacity should be identified on the basis of physical inspection of the unit and current architectural drawings. Historically, as the census declined, many organizations began taking beds out of service and typically redeployed selected patient rooms on each unit to accommodate increasing equipment storage needs, new ancillary and clinical staff, or point-of-care services. In some cases, headwalls were removed and toilet and bathing facilities reconfigured; in other cases, these features were preserved so that the rooms could be redeployed with minimal cost as demand changed. The design capacity refers to the total number of beds that could be redeployed for patient care with minimal renovation—for example, patient rooms temporarily used as offices or storage rooms with the headwalls and utilities still intact.Exhibit 5.2 shows a breakdown of a hospital with 290 total beds, including the following details: The nursing units located in the newer east wing provide generously sized private patient rooms with contemporary toilet and bathing facilities and appropriate support space. The nursing units located in the north wing have a sufficient number of private rooms (79 percent) and an appropriate amount of space per bed (507 DGSF). Although six of the beds on each unit are located in semiprivate rooms, with 25 patient rooms and 28 beds on each unit, the semiprivate rooms would not need to be occupied by more than one patient until the census exceeds about 90 percent. The older units in the south wing have few private rooms and an inadequate amount of space to support the staffed beds (283 to 354 DGSF per bed). The rehabilitation unit (4-South Wing) is particularly problematic, with only 283 DGSF per bed and no private rooms. Rehabilitation units with an extended length of stay generally require more DGSF per bed than an acute care nursing unit to provide central dining, therapy, and family and visitor space; with all beds in semiprivate rooms, high occupancy rates are unlikely. Even though the hospital possesses design capacity for an additional 11 beds in the south wing, deployment of former patient rooms is unlikely, given that the support space is already insufficient for the beds currently staffed. Although the south wing is severely lacking in private patient rooms, simply converting the semiprivate rooms to private rooms would not be an option because it would reduce the unit sizes in such a way that efficient staffing patterns would not be possible—for example, a 14-bed unit. Compared with the medical/surgical intensive care unit (MSICU), the cardiothoracic intensive care unit (CICU) is severely undersized (364 versus 692 DGSF per bed); one of the original ten patient rooms in the CICU has already been redeployed for equipment storage. The mother–baby unit was originally designed with all semiprivate rooms, but 12 of the original semiprivates are used as privates because of declining census; support space is adequate for the 20 beds currently staffed. The pediatric unit staffs all of the original semiprivate rooms as single-bed rooms, but because of the continued low census and the shift to same-day and outpatient settings, the nine rooms are often used as an overflow for adult same-day and observation patients.Although not shown in exhibit 5.2, comparison of the NSF of the patient rooms (inside wall-to-wall dimension, excluding the toilet and bathing facilities and the access alcove) is also useful if a variety of nursing units had been constructed or upgraded at different points in time. A review of the NSF of a typical private and semiprivate patient room on each nursing unit indicates whether an inadequate DGSF per bed ratio is a result of minimally sized patient rooms or a lack of support space, or both. Any code-compliance issues with either the size of the patient rooms or the size and access to the contiguous patient toilet and bathing facilities should also be identified.Capacity of Major Clinical ServicesHealthcare organizations vary to a surprising degree in the number of expensive procedure rooms and equipment units that they use to accommodate similar numbers of annual procedures. This variation is why it is important to look at the current capacity of specific clinical services prior to expanding the number of procedure rooms and related support space, particularly those services that use expensive equipment and require uniquely designed procedure rooms. Key questions to ask prior to committing significant dollars to expanding or upgrading a department include the following: Is the current equipment state of the art? Would newer, upgraded equipment improve throughput and thus eliminate the need for additional procedure rooms? Can the current procedure rooms accommodate new, upgraded equipment, considering size and dimensions, ceiling height, floor loading capacity, and power and telecommunications requirements?
Identifying Facility Needs and Establishing Priorities. Could the daily and weekly hours of operation be extended to allow more procedures to be performed per week with the existing or upgraded equipment, such as staffing the department during evening or weekend hours? Even if the current number of procedure rooms is sufficient, is support space adequate to allow the department to function efficiently and to meet customer service needs, including staff work areas; supply storage; and patient waiting, reception, preparation, and recovery space? Would relocating the department to an alternate location facilitate the sharing of staff, enhance customer convenience, or allow procedure rooms or support space to be shared with another department or service? Would a newly configured or relocated department reduce staffing costs, increase workloads and corresponding revenue, or provide other quantitative benefits that would balance the initial capital cost of equipment acquisition and facility renovation or construction?Exhibit 5.3 summarizes general capacity benchmarks for key diagnostic and treatment services, assuming target procedure room turnaround times and moderate technology implementation. The exhibit then identifies the optimal annual number of procedures that a single piece of equipment or procedure room can accommodate. The annual capacity is determined by first identifying the number of procedures or visits that can optimally be scheduled in an hour, as well as the number of hours per day that the department will be staffed, and then by assuming 50 weeks per year of operation (allowing for about ten holidays). Some factors that influence procedure room turnaround time include the following:images Technology. With a traditional, single-slice computed tomography (CT) scanner, patients were scheduled every 30 minutes so that each procedure room could accommodate 16 patient studies or procedures per day based on an eight-hour day. The newer scanners can acquire multiple images per second, resulting in an average procedure time of less than ten minutes. This efficiency allows four patients to be scheduled per hour, or twice the number as with the older unit. (Identifying Facility Needs and Establishing Priorities)
Patient mix and scheduling patterns. Physician practice space and clinics will have varying use of their exam rooms depending on the type of patients being seen (e.g., dermatology, general surgery, oncology, and pediatrics), teaching obligations, and scheduling patterns such as evening and weekend sessions. Responsiveness of support services. The time required to prepare a surgical OR for the next case (OR turnover time) has a significant impact on the daily number of cases that can be accommodated in a single OR. Responsiveness of other hospital departments. The turnaround of emergency department (ED) exam and treatment cubicles is greatly influenced by the responsiveness of the central laboratory and imaging departments if point-of-care services are not available; a shortage of inpatient beds can cause patients, who need to be admitted, to back up in the ED. The responsiveness of consulting physicians also affects patient throughput.Physician Practice Space and Outpatient ClinicsPhysician practice space was traditionally planned assuming two exam rooms and an office for each physician. The space was dedicated for use by a specific physician, regardless of the hours per week he was present. Because of the competing responsibilities of most physicians, exam rooms were typically underused, especially on Monday mornings and Fridays, with peak demand midweek.
Identifying Facility Needs and Establishing Priorities The variance between peak-volume and low-volume days is even more pronounced in academic medical centers, where medical faculty also have teaching and research responsibilities that further reduce (and affect the scheduling of) their time in outpatient clinics.The space needed for physician practices and outpatient clinics is usually based on the anticipated schedule and staffing patterns. Planners typically provide two exam rooms per provider, although high-volume, quick-turnaround specialties—such as dermatology and orthopedics—may effectively use three exam rooms per provider. However, the weekly number of visits per exam room should also be calculated to identify whether exam rooms alanning issues.(Identifying Facility Needs and Establishing Priorities)