3 Key Department Informationparklandhospital_rfp.s3.amazonaws.com/rfp_id/938...6HF 1 KARLSBERGER...

3 Key Department Information

Karlsberger Healthcare Consulting

Planning | Strategy | Operations | Programming

Stacking Diagrams



1KARLSBERGER PROJECT NO. 30-0002AAMARCH 18, 2009

Parkland Health and Hospital System Operational Planning

LOWER LEVELBUILDING STACKING DIAGRAM

CENTRAL STERILE

LOADING / MECHANICAL

MORGUE

SERVICE ELEVATORS

VISITOR ELEVATORS



FIRST FLOOR at gradeBUILDING STACKING DIAGRAM

EMERGENCY SERVICES

IMAGING - RADIOLOGY

INMATE UNIT

ICC

LOBBY / SHARED

PSYCH ED

SERVICE ELEVATORS

VISITOR ELEVATORS



SECOND FLOOR at gradeBUILDING STACKING DIAGRAM

MEDICAL RECORDS

RESPIRATORY ADMIN

LOBBY

CAFETERIA / DIETARY

PUBLIC SERVICES

CHAPEL

BLOOD BANK

CLINICAL PATHOLOGY

ANATOMIC PATHOLOGY

PHARMACY

SERVICE ELEVATORS

VISITOR ELEVATORS



THIRD FLOORBUILDING STACKING DIAGRAM

PUBLIC

SURGERY / ANESTHESIOLOGY

ECU

OB TRIAGE / OBSERVATION

O.R.’s

SURGERY / GYN / C-SECTION

LABOR & DELIVERY

SERVICE ELEVATORS

VISITOR ELEVATORS



FOURTH FLOORBUILDING STACKING DIAGRAM

CCU / TLEMETRY UNIT

CATH and ENDO

NNICU

SERVICE ELEVATORS

VISITOR ELEVATORS



FIFTH FLOORBUILDING STACKING DIAGRAM

MECHANICAL

SERVICE ELEVATORS

VISITOR ELEVATORS



SIXTH FLOORBUILDING STACKING DIAGRAM

SICU

BURN UNIT

POSTPARTUM

ANTE PARTUM

SERVICE ELEVATORS

VISITOR ELEVATORS

MED SURG



SEVENTH FLOORBUILDING STACKING DIAGRAM

MICU

POSTPARTUM

SERVICE ELEVATORS

VISITOR ELEVATORS

APHERESIS / DIALYSIS

MED SURG



EIGHTH FLOORBUILDING STACKING DIAGRAM

PSYCH UNIT

MED SURG

REHAB

POSTPARTUM

SERVICE ELEVATORS

VISITOR ELEVATORS



NINTH FLOORBUILDING STACKING DIAGRAM

MED SURG

POSTPARTUM

GYN ONC

SERVICE ELEVATORS

VISITOR ELEVATORS

HEM-ONC

GCRC



ALL FLOORSBUILDING STACKING DIAGRAM

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Stacking Narrative



Functional Stacking Narrative

The space program for the future Parkland Memorial Hospital is intended to provide

large fl exible spaces that will be timeless and allow for adaptability as technology,

science and clinical medicine change over time. All patient care rooms are

programmed to be universal and meet TAC for ICU which will provide maximal

fl exibility to adapt spaces for patient acuity, service line design or future changes to

operating models.

The hospital space program is one part of the larger campus vision, which in addition

to the hospital includes the future administrative building and the future clinic

building.

This narrative will discuss the vision for the replacement hospital fl oor by fl oor. It

will also point out the most critical adjacencies.

This stacking diagram presents a vision of 3 patient care towers: a woman’s and two

adult non-woman’s towers, organized with a service line or center of excellence

vision. It is envisioned that all towers will be connected horizontally.

Lower level:

The lower level of the hospital will house Central Sterile Processing and the Morgue.

Central Sterile Processing will be centralized in the new hospital and support all

sterile processing on the PHHS campus, for the hospital (except fl exible endo and

bronchoscopes), the clinic and outpatient areas. Vertical adjacencies via clean and

soiled elevators for the transportation of case carts and distribution of supplies and

instruments is required. As the clinic building is programmed additional vertical and

horizontal connections will need to be further studied.

The Morgue will need access to the outside via a dock for funeral homes to pick up

bodies.

Central Logistics is planned to be in the basement of the clinic building. Connections

for the effi cient distribution of supplies and equipment throughout the entire hospital

will need to be further analyzed during the design phase of this project.

First Floor:

The Emergency Department, ICC, Psych ED, Inmate Unit Treatment Center and

Imaging will be located on the fi rst fl oor of the hospital.

Coordination of drive-up, drop-off and parking will need careful attention. The lobby

entrance used for foot traffi c should be located away from EMS traffi c.

The circulation and fl ow of patients, EMS and staff during a crisis situation, requiring

decontamination, should also be considered and studied further during the next

phase of this project.

The ICC is intended to be adjacent to the main ED with a backstage connection for

woman who require emergent ED services. Elevators providing a vertical adjacency

to L&D are required.

The psych ED is programmed to have adjacent access to the sallyport for patients

who are brought in by police escort. The psych ED requires a backstage connection

to the ED to accommodate psych patients who require care services from the main

ED.

The inmate unit and treatment center will be directly adjacent to the sallyport. This

unit will have a priority adjacency to radiology as no imaging services are planned for

the inmate unit, other than portable imaging capabilities. An off-stage hall way is

requested to safely and securely transport prisoners, who require ED services, from

the inmate unit to the ED.

Sec3:12

A separate EMS entrance is envisioned. This entrance should be designed to provide immediate access to the resus rooms in the

main ED. An elevator providing a direct vertical adjacency to the OR and cath lab from this space is planned.

The radiology department will support all inpatient and outpatient imaging services. Adjacencies providing effi cient access to the

clinic building and inpatient areas is critical.

Second Floor:

Two distinct entrances and lobbies are planned; one for the main hospital and one for woman’s services. The Gift shop, patient

relations including interpreters, and the cafeteria are planned to be located off the main lobby in a highly visible location, with lots

of traffi c.

Clinical and anatomic labs are planned to be located on the second fl oor across the hall from each other. Backstage connections

are required to transport specimens between the two spaces. Organized, sophisticated connections via a pneumatic tube system

are essential. Off-stage vertical and horizontal connections to clinical care areas including the OR and ED are necessary for the

transport of specimens that cannot be transported via pneumatic tube.

Blood bank is planned to be either on the 2nd fl oor with vertical adjacencies to the OR and ED or within the OR suite with a

vertical adjacency to the ED.

ADT requires easy access to the patient care areas, the ED, discharge lounge and the observation unit.

The discharge unit requires easy access to the pharmacy so patients can pick up prescriptions while they wait for a ride home

after being discharged.

The eligibility center will service the entire hospital. Many outpatients are serviced here, so a close adjacency to the main lobby

would be preferred.

Third Floor:

The Consolidated OR suite, which includes: 23 OR’s, supporting spaces and recovery, intra-operative MRI, blood bank, frozen

section/grossing room, satellite pharmacy, is located on the 3rd fl oor adjacent to Labor and Delivery.

The OR and L&D require vertical adjacencies to sterile processing, the ED / ICC, patient care units, blood bank, and the

laboratories.

The general OR’s require vertical adjacency with designated elevators to transport patients from the ED, to and from the Burn

unit, and SICU. Vertical adjacencies to all patient care areas are important, but the ED, Burn and SICU require designated, clean

elevators that can be designated to stop only at specifi c fl oors for purposes of the emergency transportation of patients.

The labor fl oor requires a designated elevator to transport infants to the NNICU. Vertical direct access from the antepartum unit

to the labor fl oor is also essential.

The C- section OR’s, ECU and recovery spaces should all be contiguous to create maximal fl exibility and support anesthesia

cross coverage.

Fourth Floor:

The NNICU will be located on the fourth fl oor with a vertical adjacency to the labor fl oor. The NNICU is a self contained unit and

includes spaces for procedures, satellite pharmacy, formula room, storage, transport, child -life and therapists, family space and

staff support spaces A plan for the effi cient and emergent transport of a sick infant to Children’s Hospital needs to be further

discussed during the next phase of this project to ensure that the most effi cient vertical and horizontal offstage routes are

identifi ed.

The interventional unit which is comprised of non-invasive inpatient cardiac services, invasive cardiac services and the GI /

Bronch suite will be located on the 4th fl oor. A shared recovery space is planned to maximize effi ciency and anesthesia coverage.

A vertical adjacency to the ED is essential. Vertical adjacencies to the ICU’s (MICU) and patient care units is required.

Communications with anatomic lab, sterile processing and pharmacy are also important.


Sec3:13

Strategic Question: A 36 bed patient care unit is planned for this fl oor. The unit has been titled CCU and was envisioned to have

a combination of ICU beds (12) and acute care beds(24) and care for patients requiring medical and surgical cardiac care. It was

envisioned that the telemetry command center could be part of this unit. Depending on the confi guration of patient type vertical

adjacencies to the OR and ED are necessary as well as a horizontal adjacency to the cath lab. The future vision for cardiac and

cardiothoracic services is still being discussed among PHHS senior administrative and medical leadership.

Another thought: the cardiac population could be accommodated on other patient fl oors and this unit could become the

observation unit, where patients requiring less than 24 hour LOS would be managed. This unit is a standalone unit and doesn’t

offer future fl exibility afforded on the other fl oors where care units have horizontal adjacencies.

Fifth Floor:

Mechanical

Sixth Floor:

Womans:

This fl oor will house either (2) 36 bed Postpartum / Newborn Nursery or (1) 36 bed Antepartum (1) 36 bed Postpartum unit

Vertical adjacencies to L&D, NNICU are required.

Strategic Question: Could the antepartum unit be moved to the 9th fl oor with the GYN ONC unit. This would allow one less NBN

to be built (which was not programmed).

Adult non-woman’s: Surgical ICU, Burn Service and Subspecialty Service Lines / Trauma Institute

This fl oor is envisioned to be organized with surgical services. The 32 bed burn unit with all its’ required support spaces and a

36 bed SICU are envisioned to be in one tower. These units require a clean elevator, vertical adjacency to the OR and ED. Two

acute care 36 bed units are planned to be in the adjacent tower. In accordance with a service line or center of excellence

approach these units could accommodate surgical subspecialty and trauma patients. The Neuro surgical ICU could be

accommodated on one of these units (12 beds), covered by the neuro-intensivists. The adjacent acute care beds could

accommodate medical and surgical neuro / stroke patients. A vertical adjacency to radiology specifi cally CT and MRI are

required. The Epilepsy monitoring station could be part of this unit. The horizontal adjacency between these units will

accommodate programmatic growth and fl uctuation in census. The ICU satellite pharmacy will be located on this fl oor or the 7th

fl oor.

Seventh Floor:

Woman’s:

Woman’s (2) 36 Bed Postpartum / NBN. Vertical adjacencies to L&D, NNICU are required.

Adult non-woman’s: Medical ICU and Subspecialty Service Lines

This fl oor is envisioned to be organized with medical services. The 36 bed MICU, which requires vertical adjacencies to the ED,

GI/Cath lab are required.

It is envisioned that the adjacent acute care unit will manage patients with end stage renal disease (ESRD), renal transplant and

other nephrology patients. This unit will either be 24 or 36 beds the apheresis / dialysis unit will be adjacent to this space. This

will provide the requested horizontal adjacency between the nephrology unit and dialysis and the MICU and dialysis. The

additional (2) 36 bed acute care units on this fl oor can support patients with other medical conditions: IDDM, pulmonary,

infectious disease, etc. A vertical adjacencies to the GI/Cath lab, imaging- specifi cally MRI and CT are required. The ICU satellite

pharmacy will be located on this fl oor or the 6th fl oor.

Eighth Floor:

Woman’s

Woman’s (2) 36 Bed Postpartum / NBN. Vertical adjacencies to L&D, NNICU are required.


Sec3:14

Eighth Floor cont.

Adult non-woman’s: Rehab. / Trauma Institute

It is envisioned that the 24 bed psych unit will be part of this fl oor. This unit requires a vertical adjacency to the psych ED.

The 24 bed Rehab unit with support space is envisioned to be adjacent to (2) 36 bed acute care med/surg units. It is envisioned

that these adjacent units could provide fl exibility for PMR overfl ow and in the future support an expanded vision (60 beds) for

PMR. It is envisioned that patients who require some level of rehabilitation, such as stable post trauma or stroke, orthopedic,

gerontology, patients will be cared for on the units adjacent to the rehab unit. The satellite PT/OT gym should be located in the

core between these units to provide effi cient care and maximum fl exibility.

Ninth Floor : Hematology/Oncology Service Line or Cancer Center of Excellence

Woman’s:

This fl oor will house either (1) 36 bed Postpartum / Newborn Nursery or (1) 36 bed Antepartum and the 28 bed GYN-ONC unit

and infusion center.

Vertical adjacencies to L&D, NNICU are required.

Strategic Question: Could the antepartum unit be moved to the 9th fl oor with the GYN ONC unit. This would allow one less NBN

to be built (which was not programmed).

Adult non-woman’s: Hematology/Oncology:

Four, 36 bed med/surg units are planned for this fl oor. All hem/onc medical and surgical patients would be admitted to these

fl oors. Twelve beds on one of the units would be dedicated to the GCRC. Vertical adjacencies to the OR, imaging and apheresis

are required. A vertical adjacency to pathology is requested. Safe and effi cient access to radiation therapy will need to be

further discussed during the next phase of this project. Currently radiation therapy is programmed to be on the fi rst fl oor of the

clinic building. The oncology satellite pharmacy, which mixes all chemotherapy will be located in the clinic building. Transport

of chemotherapy to the inpatient heme/onc and GYN-ONC units needs to be further discussed.


Sec3:15

Functional Narratives



Functional Narratives are the operational narratives that defi ne the space. Each

narrative contains the following information:

SCOPE OF SERVICES AND OPERATING PARAMETERS•

- Background / Current State Information

PLANNING CONSIDERATIONS •

- Model of Care

- Space Program

- Utilization

- Staffi ng

ORGANIZATIONAL AND KEY ADJACENCIES•

- Adjacency Diagrams (see the key below)

FUTURE FLEXIBILITY•

Adjacency Diagram Key

Functional Narrative Introduction

Sec3:16

Bubble Example Bubble Description

Department in question.

Very Close / Critical Adjacency

Close adjacency

Easy access

Interactions impact workflow and adjacencies or easy access should be considered.

Example

Example

Example

Example

Example

THIS FUNCTIONAL NARRATIVE IS ASSOCIATED WITH THESE SPACE PROGRAMS:

Critical Care Units•

Patient Care Unit Floor Core (ICU)•

Med/Surg Unit•

Patient Care Unit Floor Core (Med/Surg)•

PLANNING WAS INFORMED BY THE FOLLOWING:

Proven Evidence Based Design•

Identifi ed Best Practices•

Completed Staff Questioners•

User Group Discussions•

PWC- PHHS Strategic Planning Document •

SCOPE OF SERVICES AND OPERATING PARAMETERS:

Currently Parkland Hospital has a complement of 24 acute care units and 5 •

ICU’s

Nurse patient ratios vary based on acuity•

Sizing of care units needs to support fl exibility in staffi ng ratios. Should be •

divisible by 2 -4 and 6.

The current inpatient acute care groupings are:

Medical/Hospitalist•

Hematology/Oncology•

Neurology•

Acute Stoke-step down•

Epilepsy monitoring•

Telemetry•

Rehabilitation•

Trauma•

Diabetes•

Pulmonary•

General Surgery•

Surgical Oncology•

Burn•

Miscellaneous surgery, Urology, Oral Ophthalmology, ENT•

Neurosurgery•

Orthopedics•

Functional Narrative - Inpatient Care

Units (Acute Care/Critical Care)

Sec3:17

The current inpatient ICU groupings are:

• CCU

• MICU

• BICU

• SICU

Background / Current-State:

The current units vary in size from 11 beds to 26 beds and are comprised of mostly semi-private rooms. •

The small size of the current rooms, do not accommodate families and make it diffi cult to integrate families into a patient’s •

care.

Presently units are organized according to service line, physician staffi ng guidelines and patient acuity.•

Supplies and medication dispensing machines are centrally located on the units requiring nurses to go to a central location •

when they need supplies.

The current medical record and order entry system is manual which creates delays in care delivery and is prone to human •

error. This system also takes nurses away from the bedside to a central location to chart, obtain orders and make changes

to the patient’s plan of care.

There is limited space on or adjacent to the units for physicians to hold work and teaching rounds, as a result they are forced •

to seek spaces away from the unit, which does not enhance a multidisciplinary or collaborative practice model of care.

PLANNING CONSIDERATIONS:

Model of Care:

Inpatient services will be provided on units of 36 and 24 private patient rooms. •

There will be two (2) 36 bed units per fl oor or (1) 36 bed and (1) 24 bed unit per fl oor in the replacement hospital. The new •

hospital will be programmed with 10 acute care medical surgical units, 3 ICU, 1 inmate (see inmate program), 1

rehabilitation unit (see rehab program), one integrated burn unit, which accommodates all levels of care, (see burn

program).

Patients requiring acute and step-down medical and surgical level of care will be managed on the acute care units. •

It is anticipated that in the future patients will be grouped on units according to disease state/service line and physician •

staffi ng for coverage. Units will be programmed to be generic but will be designed to cater to the unique features of specifi c

patient populations.

The building stacking should be arranged to support service line grouping and maximal fl exibility between adjacent care •

units.

The unit groupings take into consideration the following strategic visions: a trauma institute, cardiothoracic surgery •

returning to Parkland, expansion strategy for PMR, inmate strategy, oncology growth strategy, Parkland’s academic mission,

and future multidisciplinary operating models of care delivery.

The Epilepsy Monitoring station will be located within one of the acute care units. Twelve beds will be allocated to Epilepsy •

Monitoring; however more could be added if future patient volumes increase. There will be an electronic adjacency between

the Epilepsy Monitoring station and the neurodiagnostics center. 2 rooms on this unit will be dedicated to inpatient EEG

testing and should be designed with acoustics to reduce artifact that will interfere with EEG testing.

The Central Telemetry Monitoring station will be located within one of the acute care units. This space should be located in •

close proximity to the telemetry unit, however all patients who are on telemetry will be monitored remotely in this space.

A 320 NSF OT/PT satellite gym is planned to accommodate the therapy needs of those patients who are not on the rehab unit, •

but who require dedicated gym space for therapy. This gym should be located on the unit or in the core of the unit where

orthopedic, stroke, recovering trauma patients are hospitalized.

The optimal unit lay out will foster a decentralized operating model of care. •

Functional Narrative - Inpatient Care Units (Acute Care/ICU)

Sec3:18

Care will be organized at the patient’s bedside rather than in a central location. •

The unit should be designed to promote maximal visibility, special relationships and a lean approach to care delivery. All •

equipment, supplies and documentation tools will be within a nurse work zone. This will promote effi ciency by reducing

travel distances. The “sweet spot” for effi ciency and walking distance is 241 - 289 NSF.

All rooms with be private with bathrooms and showers.•

All critical care rooms will be telemetry capable, all acute care rooms will be wired for telemetry. •

All critical care rooms will be plumbed for dialysis. •

Consideration of lifts to assist in moving patients should be widely implemented.•

25% (9-per unit) of acute care rooms will be equipped as bariatric rooms will be plumbed for dialysis. •

Isolation (negative pressure): it is planned that 25% of the MICU beds (9) will be negative pressure, and 10% of the remaining •

beds will be negative pressure. ICRA to be done to validate the number of isolation rooms.

-36 of the negative pressure rooms should be collocated on one unit. This strategy will infectious patients to be

cohorted on one unit.

At a minimum an additional 36 bed acute care unit will be programmed to be easily converted to negative pressure in the •

event of a pandemic situation. This space should be designed in such a way that it could be quarantined from the remaining

hospital space. Parkland leadership will continue to work with infectious disease physicians and clinicians to develop a

response plan for a pandemic situation. The details of this plan will be further fl ushed out with the architect and engineer

during the design phase of the project.

The design of horizontal pathways and vertical transporting systems to reduce the physical demand on personnel servicing •

multiple units and departments should be employed in the design. Separate onstage and offstage functions will support

patient, public and logistics traffi c, both vertically and horizontally.

Nursing Model of Care:• Will remain primary with 1 nurse and patient care assistant to a designated number of patients.

Medical Model :• Parkland will continue its mission of teaching residents and medical students. Changes in CMS guidelines,

physician shortages and the increasing acuity of hospitalized patients are driving the development of hospitalist programs,

increased use of midlevel providers, and more on-service time for existing attending physicians. The new space needs to

accommodate these clinicians 24/7. Provisions for designated available space for educational activities, offi ces and call

rooms will be allocated.

Grouping and Size of IP Care Units


Sec3:19

Critical Care Patient Units Notes/ Comments # of Rms

Board Approved DGSF 11/4/08

KHC 2/22/09 Revised 3/4/09

KHC SHELL 2/22/09Revised 3/4/09

Critical Care Units 3 units of 36 beds + a burn unit.

Critical Care Units 3 units of 36 beds each = 108 critical care non-women’s beds

108 76,500 82,491

Burn Unit 32 beds (20 acute and 12 ICU): Urgent Care, OR/Procedure Room, Outpatient Burn

32 45,000 30,299

Patient Care Unit Floor Core

4 units total require 2 cores at 6,593 DGSF 0 12,701

Med/Surg Patient Units 9 med/surg units, 2 shell, 1 rehab unit, 1 psych unit, and 1 inmate unit

Med /Surg Unit 9 units of 36 beds each: 324 beds 324 216,000 245,687

Med/Surg Rehab Unit 1 unit of 24 beds 24 26,135

Psych Bed Unit 1 unit of 24 beds 24 27,000 24,306

Inmate Unit and Treatment Center

1 unit of 12 beds; Urgent Tx and Exam Rooms (incl. core functions)

12 16,799

Patient Care Unit Floor Core

6 cores total – one core per floor serves two units (each core is 6,593 DGSF)

38,102

Apheresis/Dialysis Unit Locate on the same floor as nephrology beds 8,274

Satellite PT/OT Gym Locate in the Floor Core on the Ortho Floor (or wherever the team feels is appropriate

320

Epilepsy Monitoring (see M/S unit program note at end

Epilepsy monitoring room thatneeds to be located on one med/surg unit

360

EEG/Sleep Move to clinic 4,400

Central Telemetry Monitoring (See M/S unit program note at end)

Telemetry monitoring rooms that need to be located on one med/surg unit

360

SHELLED M/S Unit 2 unit of 36 beds 72 54,597

SHELLED Core to go with Unit

1 core 6,350

Source: Kaufman Hall 2006 data (9months annualized), Price Waterhouse Coopers(PWC) Volume Capacity, Projections. Master Facility Plan, June 2007.

Patient Arrival

• Unit Transfer• Bed Assigned• Equipment

ordered/delivered to room

• Electronic report sent to receiving RN

Patient Arrives

Bedside registration completed, if necessary

Patient care assignment made

Initiation of Care

Care Delivery

Patient assessment performed

Orders initiated electronically

Monitoring:Hardwire, invasive,

telemetry

Medication System• Pyxis modules located

near patient rooms at ratio of 1 set per 18 patients

• Clinical pharmacists available for discussion

• Special items provided via P. Tube.

Supplies• Patient specific items

added to in-room supply cart

Equipment• Available on the unit or

from Distribution or Biomed

Food Services• Meals ordered

electronically• Room Service Model• Nutritional services• Coordinates with

nursing for feeding.

Documentation• Done at bedside,

decentralized areas, or work room.

• As many systems as possible are electronically integrated into the EMR.

Lab• Specimens drawn at

bedside• Testing utilizes POC: in

room, in surgery• P. tube used for

specimen transport• Results electronically

produced.

Surgical Intervention/ Procedures

• Transport to Surgery/Procedure area

• Emergencies may require in room intervention for some procedures

• Patient returned from Recovery Area or directly from Surgery/Procedure area

Therapies• Bedside administration

• Respiratory• PT/OT/ST• EKG• EEG

• Department administration• PT/OT/ST• Cardio Diagnostics• Neuro Diagnostics

Imaging• Provided with portable

equipment at bedside or transported to Imaging Department

• All imaging is digital and viewed in PACS.

• Some key Imaging services located on IP Units (CT)

Discharge Process

• Starts on Admission• Case Manager/Social

Worker assigned at admission

• Team conferences case review occurs on regular schedule

Appropriate placement arranged

Discharge orders received.

Patient transferred or discharged.

Future State Process Flow


Space Program:

Unit Size:• Future confi gurations will be standardized and should allow nurse patient ratios to be divisible by 2-4-6. A

standardized 36 private-bed unit is planned to provide operational fl exibility.

Unit Sub-divided: Units• can be subdivided into smaller pods or groupings. These smaller areas could be grouped to

accommodate staffi ng and care for specifi c patient populations. ICU’s could be sub-divided into four i.e. Neurosurgical ICU.

Unit Layout:• The use of single patient rooms will increase the footprint size of the patient care units, thus the space design

must maximize visibility, spatial relationships and reduce travel distances. In addition staff to staff communication via

advanced technology will be essential.

Electronic Environment• : It is envisioned that the new hospital will be completely electronic. It is presumed that all

documentation, order entry, monitoring, etc. will take place at or in close proximity to the patient’s bedside.

Transportation:• Horizontal pathways and vertical transportation systems will be programmed. They must reduce the

physical demand on personnel servicing multiple units and departments. A sophisticated pneumatic tube system is planned

as a critical component to the medication/supply/specimen delivery system. Medication delivery will utilize automated

dispensing machines (Pyxis) with medication stocking by pharmacy. Specialty or emergency delivery of products will be

accomplished by pneumatic tube.

Reception / Family Waiting: • Space will be programmed to accommodate patient’s families. Integration of family centered

care principles will be paramount in the new hospital.

Sec3:20

Patient Room: • The rooms will feature 3 distinct zones: family, patient and staff. Family centered care will be a cornerstone

of the new facility. Distinct spaces and amenities that reach-out to and foster the inclusion of families in patient care area

planned.

-Room Standardization: Rooms will be standardized with regard to the location of medical gases, systems and supplies.

This concept will enable providers to experience an identical environment in each patient room.

-All rooms with be private with outboard bathrooms and roll in showers.

-All ICU rooms will be plumbed for dialysis.

-All rooms will be private, universal and wired for telemetry. This will provide fl exibility with changes in patient census

and acuity.

-Isolation rooms will be distributed through-out the specifi cs to be determined by ID/IC plan.

-Future Flexibility: A Universal Room Concept will be utilized to provide a fl exible, physical environment that supports

varying acuity of patients and avoids multiple transfers. Blocks or modules of rooms can be designated for specifi c

acuity levels or disease populations.

Medication Administration:• Each unit will have a secure med room at a 1:18 ratio. This room will provide space for

medication storage and supplies for dispensing medications. In addition each patient room will be designed with a nurse

server. A system which utilizes medication distribution to a patient specifi c space reduces medication errors.

Team Work Space:• Spaces will be programmed to support both unit and visiting professional staff.

- The new space will feature decentralized work spaces at the patient bedside. Alcove work stations with computers

will be programmed at a ratio of 1 for every patient room.

- Clinical Support Team Workroom: Centralized “touchdown” space for staff collaboration and work space for visiting

staff will be programmed on each unit.

- Support Space: Separate onstage and offstage functions and patient, public and logistics traffi c (both horizontal and

vertical) will be programmed. Larger spaces can accommodates teaming, planned meetings and educational

programs.

Provider Spaces: • Each unit has designated provider workrooms to accommodate provider rounds and workspace. In

addition each unit core has a Resident Learning Center (LRC) and offi ce space to support 2 fellows (Fellow LRC).

Specialized Service Flexibility:• In the future the acute care units will have the fl exibility to provide specialized common

treatment modalities and monitoring that they have not had the ability to provide because of space constraints. Provision of

this care will afford future fl exibility to respond to patient clinical needs, acuity, fl uctuating census and staffi ng, for example:

- Telemetry monitoring - future state all rooms will be wired

- Flexibility to manage step-down patients in the acute care units including those on ventilators

- Increased number of patients with complex co-morbidities whose care will require increased task, education and

patient/ family collaboration.

- Increasing infection control concerns and regulatory policy constraints

- Increased volume of bariatric like patients will increase the physical demands placed on staff

- Increased number of cognitively challenged patients: aging population, borderline psychiatric population.

Specialized Population Specifi c Space:• Flexible space will be built into the unit core which will provide future ability to have

specialized equipment i.e. satellite therapy gym on or in close proximity to patients requiring rehab therapy but are not on the

rehab unit.


Sec3:21


Sec3:22

Reception / Waiting Patient Rooms/ Clinical Care (Space:Pt)

Unit Core (1:18) Unit Support Vertical Transportation

Reception / Information and Control (1:72)

Patient Room 36 regular;Isolation per ID/IC

Storage Equipment,General

Communication Center (1:36)

Support Elevators – 1 bank of multiple elevators per 36 patients

Waiting / Family Lounge,Library (1:72)

Decentralized staff workstation (1:1)

Stretcher / Wheelchair Storage

Respiratory Therapy (1:72)

Patient elevators – 1 bank of multiple elevators per 72 patients

Family Consult Room (1:72)

Provider work rooms1:9 vs. 1:18

Public Trash & Recycling Pantry Staging Patient Elevators – 1 bank of multiple elevators per 72 patients

Clinical Support Team 1:36 Soiled Holding Staff Lounge and Locker Room (1:72)

Pointof Care Testing 1:18 Linen MD Hoteling Office (2:72)

Medication Room 1:18 Clean Supplies Unit Manager Office 1:36

Galley / Staff Nutrition 1:18 EVS Shared Office (4:72)

Family Nutrition 1:18 Staff Bathroom Fellow Office (LRC)(1:72)

Emergency Equipment Alcove 1:9 Conference Room (one lg. one small:72)

Pneumatic Tubes 2:36


Utilization / Hours of Operation:

24 hours a day- 7 days a week •

- Most admissions occur between 3 PM - 11 PM

- Most discharges occur between 12 PM – 4 PM

Staffi ng:

Staffi ng ratios may vary by unit, new space should support fl exible ratios and be divisible by 2-4-6. HUC, PAC future roles •

will change with decentralized units and EMR- need further discussion.

Staff work 8 hour shifts on the acute care units and 12 hour shifts in the ICU’s •

There are between 16 - 20 members of the nursing staff on the unit at any one time.•

There are between 4 - 15 staff (allied health, attending physicians, students, etc.) on the unit at any given time.•

ORGANIZATIONAL AND KEY ADJACENCIES:

The inpatient acute care units should be easily accessible to staff, materials management, visitors, the operating rooms and •

the emergency department.

Designated elevators for staff, patients, visitors and supplies to decrease travel time, improve effi ciency and patient safety •

will be programmed.

In the future state operating model staff from cross-disciplines will be dedicated to specifi c units, hoteling space will be •

provided.

The new space will accommodate phlebotomy staff and direct access to clinical lab, via pneumatic tubes. •

ICU rooms and a percent of acute care rooms will be plumbed for dialysis. •

Therapists will have space for supplies to accommodate unit based therapy. •

Consideration should be given to the following intuitive adjacencies when the building is stacked:•

- Placement of Hematology/Oncology and Surgical Oncology patient populations

- Medical / Surgical Oncology and GYN Oncology

- Medical / Surgical Acute Care patients requiring therapy services adjacent to Acute Care Rehab. Unit

- Medical Acute Care Unit caring for nephrology patients adjacent to Dialysis Unit

- Dialysis Unit Vertical adjacency to ICU

- SICU with vertical adjacency to the OR

- GCRC and Oncology

- ICU’s with vertical adjacency to OR and ED

- CCU and telemetry vertical adjacency to OR and Invasive / Non-invasive cardiology

- Clinical lab, blood bank, and pharmacy adjacency needs will be met with pneumatic tubes.

- Potable imaging, ECHO, EEG will be available bedside in the ICU’s and on the acute care units as necessary

- Neuro ICU adjacency consideration to CT


Sec3:23

Adjacency Diagrams

FUTURE FLEXIBILITY:

All inpatient rooms will be universal and sized to meet Texas Administrative Code – ICU requirements, to provide a fl exible,

physical environment that supports the varying acuity of patients and avoids multiple transfers. Blocks or modules of rooms can

be designated for specifi c acuity levels or disease populations.

The plan for how the units are confi gured in the new building should allow for fl exibility across units to accommodate

programmatic growth, changes in science, technology and disease management and fl uctuation in patient census.


OR

Imaging

Pharmacy

Pathology

Clinical Lab

ED

MRI

PM&R

ICU ICU

Imaging

Dialysis

ED

Sec3:24


Burn Unit with Specialty Procedure Space•

Patient Unit Floor Core•









The Regional Burn Program at PHHS is accredited by the American Burn •

Association, ABA. The center has received verifi cation by the ABA and the

American College of Surgeons.

Burn center verifi cation is a mark of distinction and indicates to government, •

third party payors, patients, and accreditation organizations that the center

provides the highest quality care and meets the rigorous qualifi cations outlined

by the ABA for accreditation.

The program at Parkland cares for patients of all ages. Over the last year the •

burn program has noticed increased volumes. It is hypothesized that volumes

have increased as a result of hurricane Katarina and the closing of burn centers

in nearby regions. However, the exact source and sustainability of the volume

increase has not been further studied. Additionally, there are patients with skin

sloughing disorders that could benefi t from the services provided by the

Parkland burn program.

The current burn program is divided into two units (acute care unit and ICU), •

located on two different fl oors.

There is a burn urgent care center located adjacent to the burn unit. This center •

is staffed by nurses and treats patients with minor burns; outpatient dressing

changes and wound care. The wound care space is ineffi cient and too small to

service the growing number of burn patients who seek this outpatient service.

Currently there are 2 physicians who manage the burn service (ICU, acute care •

units, surgical procedures, ambulatory clinics, teaching and research) 24/7.

Because of the demanding workload, acuity of patients and manpower it is

imperative that all burn services be co-located or in very close proximity to each

other.

The current burn ICU is 9 beds and the current acute care unit is 16 beds. Nurse •

patient ratios on the acute care unit are 1:4-6. Patient care assistants also care

for patients, this staffi ng ratio varies depending on patient need. The ICU is

staffed with ratios of 1:1 or 1:2 depending on the acuity of the patient.

Currently supplies and medication dispensing machines are centrally located on •

the units requiring nurses to go to a central location when they need supplies.

Functional Narrative - Burn Unit with Speciality Procedure

Spaces

Sec3:25

The current medical record and order entry system is manual which creates delays in care delivery and is prone to human •

error. This system also takes nurses away from the bedside to a central location to chart, obtain orders and changes to the

patient’s plan of care.

There is limited space on or adjacent to the units for physicians to hold work and teaching rounds, thus they are forced to •

seek spaces away from the unit, which does not enhance a multidisciplinary or collaborative practice model of care.


Model of Care:

The Burn Program will continue to serve patients with burns who are referred from within the region and nearby regions. •

Due to the recent closing of Shriners Burn Center it is expected that Parkland’s burn center will begin to see an increase in •

pediatric patients.

It is imperative that the program continue to be accredited by the ABA.•

The future burn space is programmed to accommodate all burn services in one geographical location. This space will •

include the acute care beds, ICU beds, hydrotherapy, therapy gym and burn urgent care exam space. In the future burn

services will be provided on a 32 bed unit, comprised of 20 acute care beds and 12 ICU level care beds. A protective

environment is planned.

Burn patients are especially susceptible to infections, a protective environment is requested. Consideration should be given •

to having isolation room (s) available. Further discussion with ID/IC is required.

Two scrub sinks will be located at the entrance to the unit to be used by all staff and visitors who enter the unit. The sinks •

should be designed to be inviting and unavoidable to ensure that hand washing and gowning is practiced by every individual

who enters the unit.

Nursing Model of Care:• Will remain primary with 1 nurse and patient care assistant to a designated number of patients.

Medical Model: • Currently there are 2 physicians who manage the burn service (ICU, acute care units, surgical procedures,

ambulatory clinics, teaching and research) 24/7. Because of the demanding workload, acuity of patients and manpower it is

imperative that all burn services be co-located or in very close proximity to each other. It is thought that this situation may

not change in the future. Parkland will continue its mission of teaching residents and medical students. Changes in CMS

guidelines, physician shortages and the increasing acuity of hospitalized patients are driving the development of hospitalist

programs, increased use of midlevel providers, and more on-service time for existing attending physicians. The new space

needs to accommodate these clinicians 24/7. Provisions for designated available space for educational activities, offi ces and

call rooms will be allocated.

Functional Narrative -Burn Unit with Speciality Procedure Spaces

Sec3:26


Sec3:27

Space Program:

Unit Size: • Future confi gurations will be standardized and should allow nurse patient ratios to be divisible by 4.

Patient Care Unit Layout: • The use of single patient rooms will increase the footprint size of the patient care units, thus the

space design must maximize visibility, spatial relationships and reduce travel distances. In addition staff to staff

communication via advanced technology will be essential.

Electronic Environment:• It is envisioned that the new hospital will be electronic. It is presumed that all documentation,

order entry, monitoring, etc. will take place at or in close proximity to the patient’s bedside.


physical demand on personnel servicing multiple units and departments. Sophisticated pneumatic tube system is planned



accomplished by pneumatic tube.



Patient Room: • The rooms will feature 3 distinct zones: family, patient and staff. Family centered care will be a cornerstone

of the new facility. Distinct spaces and amenities that reach-out to and foster the inclusion of families in patient care area

planned.

-Room Standardization: Rooms will be standardized with regard to the location of medical gases, systems and supplies.

This concept will enable providers to experience an identical environment in each patient room.

-All rooms with be private with outboard bathrooms and roll in showers.

-All ICU rooms will be plumbed for dialysis.

-The unit will be protective environment. The location of patients requiring negative pressure isolation needs further

discussion.

-All rooms will be private, universal and wired for telemetry. This will provide fl exibility with changes in patient census

and acuity.

-Future Flexibility: A Universal Room Concept will be utilized to provide a fl exible, physical environment that supports

varying acuity of patients and avoids multiple transfers. Blocks or modules of rooms can be designated for specifi c

acuity levels or disease populations.

Medication Administration: • Each unit will have a secure med room at a 1:20 ratio for acute care beds and 1:12 ratio for the

ICU. This room will provide space for medication storage and supplies for dispensing medications. In addition each patient

room will be designed with a nurse server. A system which utilizes medication distribution to a patient specifi c space

reduces medication errors.

Code Carts:• A pediatric emergency cart with pediatric and infant defi brillator will be located in each unit.








programs.



Specialized Service Flexibility: • In the future the acute care units will have the fl exibility to provide specialized common



-Telemetry monitoring- future state all rooms will be wired

-Flexibility to manage step-down patients in the acute care units including those on ventilators

-Increased number of patients with complex co-morbidities whose care will require increased task, education and


-Increasing infection control concerns and regulatory policy constraints

Specialized Population Specifi c Space: •

-Hydrotherapy tanks, therapy gym, wound care treatment/exam rooms will be programmed as part of the unit.

-Age appropriate recreation/therapeutic space will be programmed: playroom, teen-room, adult day room.


Sec3:28



-The average daily census is 19.9 which is a 86% occupancy.

-The average length of stay is 14 days.

-Most admissions occur around 5pm

-Most discharges occur around 11am

Staffi ng:

Staffi ng ratios may vary by unit based on acuity. The new space needs to be divisible by 2-4-6. HUC, PAC future roles will •

change with decentralized units and EMR- need further discussion.

Staff work 8 hour shifts on the acute care units and 12 hour shifts in the ICU•


Sec3:29

Reception / WaitingIn Core

Patient Rooms/ Clinical Care (Space:Pt)

Unit Core Unit Support / Floor Core

Vertical Transportation

Reception / Information and Control in core

Total Patient Rooms: 3220 acute care, 12 ICU*All protective

Storage Equipment, General

Communication Center 1:32


Waiting / Family Lounge,Library

Decentralized staff workstation 1:1


Respiratory Therapy(1:68)

Patient elevators – 1 bank of multiple elevators per ?? Patients

Family Consult Room Provider work rooms 3:32(1:ICU; 2:Acute Care)

Public Trash & Recycling Pantry Staging Patient Elevators – 1 bank of multiple elevators per 68 patients

Patient Elevators Direct to OR 1:32

Specialty Spaces Clinical Support Team 1:32 Soiled Holding Staff Lounge and Locker Room

PT/OT Point of Care Testing 2:32(1:ICU; 1:Acute Care)

Linen MD Hoteling Office (2:68)

Playroom/School Young Children

Medication Room 2:32(1:ICU; 1:Acute Care)

Clean Supplies Unit Manager Office (1:32)

Teen Room/SchoolAdult Day Room

Gallery / Staff Nutrition 2:32(1:ICU; 1:Acute Care)

EVS Shared Office (4:68)

Burn Urgent CareOutpatient Space

Family Nutrition 2:32(1:ICU; 1:Acute Care)

Staff Bathroom Fellow Office LRC(1:68)

Wound Care: Hydrotherapy and Debridement Shower

Emergency Equipment Alcove1:12 ICU Adult1:12 ICU Pediatric1:10 Acute Care Adult1:20 Acute Care Pediatric

Conference Room (one large and one small 1:68)

Pneumatic Tubes 2:32(1:ICU; 1:Acute Care)


Imaging

Pharmacy

ED

OR MRD

Pathology

Therapy / Hydro-therapy Wound

Care / Urgent Care

Acute ICU Burn


Vertical adjacency to the operating room is essential. Burn patients require multiple trips to the operating room. There •

should be a clean elevator dedicated to transporting burn patient between the inpatient care unit and the operating suite.

Vertical adjacency to the ED is planned.•

The burn unit acute should be easily accessible to staff, materials management, visitors, the operating rooms and the •

emergency department.


will be programmed.

It is planned that the burn unit will be located adjacent to the SICU to allow for patient overfl ow into that unit if the burn •

volume continues to grow.

Adjacency Diagram

FUTURE FLEXIBILITY:

Universal rooms will offer staff the ability to fl ex care up and down as a patient’s clinical condition. •

Universal rooms offer staff the ability to fl ex rooms in response to patient acuity and census.•

The burn unit should be located with a horizontal adjacencies to the SICU and acute care unit to accommodate an increased •

census.


Sec3:30


Med/Surg Rehab Unit•



Texas Administrative Code•

CARF•






Currently Parkland Hospital has a 17 bed inpatient acute care rehab unit which •

services mainly patients requiring rehabilitation services after suffering from

traumatic brain injury or spinal cord injury.


The current unit is made up of small semiprivate rooms that not only do not •

accommodate a patient’s family, but are so small that it is diffi cult to

accommodate and maneuver patients. The bathrooms are small making it

diffi cult for patients in wheel chairs and those needing assistance to use. There

are no showers in the bathrooms.

There is minimal space for storage of patient equipment.•

Staff works as a team to care for patients. The patient care team consists of •

physicians, nurses, therapists, social workers, case managers, dietitians and

family members.

Nurse patient ratios are 1:4. Patient care assistants also care for patients, this •

staffi ng ratio varies depending on patient need. Currently supplies and

medication dispensing machines are centrally located on the units requiring

nurses to go to a central location when they need supplies.

The current medical record and order entry system is manual which creates •

delays in care delivery and is prone to human error. This system also takes

nurses away from the bedside to a central location to chart, obtain orders and

changes to the patient’s plan of care.

There is limited space on or adjacent to the units for physicians to hold work and •

teaching rounds, thus they are forced to seek spaces away from the unit, which

does not enhance a multidisciplinary or collaborative practice model of care.

The ability to care for patients in a multidisciplinary model is essential for

patients on the rehabilitation unit.

There is always a waiting list for a bed on the rehab unit. Because of• Parkland’s

mission to fi rst serve the indigent patients most of the funded patients go to

other facilities for rehab services.

Functional Narrative -Rehab Unit

Sec3:31

Space Program:

Unit Size: • Future confi gurations will be standardized and should allow nurse patient ratios to be divisible by 2-4-6. A


Nursing Unit Layout:• The use of single patient rooms will increase the footprint size of the patient care units, thus the space

design must maximize visibility, spatial relationships and reduce travel distances. In addition staff to staff communication via


Security: • Electronic surveillance or electronic access to the unit is requested as a patient safety measure to ensure patients

who might wonder off the unit are not able to do so.

Electronic Environment: • It is envisioned that the new hospital will be electronic. It is presumed that all documentation,






accomplished by pneumatic tube where applicable.



Patient Room:• The rooms will feature 3 distinct zones: family, patient and staff. All rooms will have outboard private

bathrooms with roll in showers. Ceiling lifts should be considered.

-Patient rooms will be approximately 300 SF.

-Each room will have a private ADA sized bathroom with a roll in shower.

-Some rooms will be equipped with patient lifts in the ceiling.

-Rooms will be standardized with regard to the location of medical gases, systems and supplies.

-This concept will enable providers to experience an identical environment in each patient room.

Medication Administration: • Each unit will have a secure med room at a 1:20 ratio for acute care beds and 1:12 ratio for the

ICU. This room will provide space for medication storage and supplies for dispensing medications. In addition each patient

room will be designed with a nurse server. A system which utilizes medication distribution to a patient specifi c space

reduces medication errors.

Therapy Spaces:• A therapy work station with 15 work stations and 4 computers has been programmed. This space should be

open to the gym space.

-Physical Therapy: A 2,000 NSF gym has been programmed. Patients on the rehab. unit require intensive therapy for

several hours a day. This space accommodates specialized equipment and the ability to treat 8 patients simultaneously.

-Occupational Therapy: A 720 NSF OT treatment space has been programmed. In addition a ADL Kitchen at 160 NSF,

ADL Bed Area, ADL Bathroom Area at 100 NSF and Laundry at 100 NSF has been programmed as therapy space.


Sec3:32

-Speech Therapy: Three speech therapy treatment spaces at 143 NSF (consider increasing size to 196 SF) are

programmed.

-Private Treatment Space: Private treatment space to be used by OT and ST for working with patients in a low

stimulation environment. This room should reduce sound and distracting external stimulation. Recreation/ Dining

Dining Room: • A dining / recreation room is planned.


-The new space will feature decentralized work spaces at the patient bedside. Alcove work stations with computers


-Clinical Support Team Workroom: Centralized “touchdown” space for staff collaboration and work space for visiting


-Support Space: Separate onstage and offstage functions and patient, public and logistics traffi c (both horizontal and


programs.



Specialized Service Flexibility: • In the future the acute care units will have the fl exibility to provide specialized common



-Telemetry monitoring- future state all rooms will be wired

-Flexibility to manage step-down patients in the acute care units including those on ventilators

-Increased number of patients with complex co-morbidities whose care will require increased task, education and


-Increasing infection control concerns and regulatory policy constraints

-Increased volume of bariatric like patients will increase the physical demands placed on staff

-Increased number of cognitively challenged patients: aging population, borderline psychiatric population.

Specialized Population Specifi c Space: • Flexible space will be built into the fl oor core which will provide future ability to have

specialized equipment i.e. satellite therapy gym on or in close proximity to patients requiring rehab. therapy but are not on

the rehab unit.


Sec3:33



Staffi ng:

Staffi ng ratios vary based on acuity. HUC, PAC future roles will change with decentralized units and EMR - need further •

discussion.

Staff work 8 hour shifts •

There are between 16 - 20 members of the nursing staff on the unit at any one time.•

There are between 4 - 15 staff (allied health, physician, students, etc.) on the unit at any given time.•

Sec3:34


Reception / Waiting Patient Rooms/ Clinical Care (Space:Pt)

Unit Core (1:24) Unit Support / Floor Core

Vertical Transportation

Reception / Information and Control 1:24

Patient Rooms: 24 Storage Equipment, General

Communication Center (1:24)


Waiting / Family Lounge,Library 1:24

Decentralized staff workstation 1:1


Respiratory Therapy (1:60)

Patient elevators – 1 bank of multiple elevators per 60 Patients

Family Consult Room 2:24 Provider work rooms 1:8 Public Trash & Recycling

Pantry Staging Patient Elevators – 1 bank of multiple elevators per 60 patients

Specialty Spaces Clinical Support Team 1:24 Soiled Holding Staff Lounge and Locker Room (1:60)

OT Spaces Point of Care Testing 1:!2 Linen MD Hoteling Office (2:60)

PT Spaces Medication Room 1:12 Clean Supplies Unit Manager Office (1:24)

Speech Therapy Spaces Gallery / Staff Nutrition 1:12 EVS Shared Office (4:72)

Recreation / Dining Room Family Nutrition 1:12 Staff Bathroom Fellow Office (LRC) (1:72)

Emergency Equipment Alcove1:12

Conference Room (one lg. one small 1:60)

Pneumatic Tubes 2:24



Model of Care:

The new rehabilitation unit will be 24 beds. •

This unit will continue to provide services to patients with spinal cord injuries and traumatic brain injury. •

This unit will be self contained and provide all the spaces to accommodate a multidisciplinary care team. •

Stable patients with tracheotomies requiring acute rehab and mechanical ventilation will be able to be safely cared for in the •

new space. A percentage of the rooms will also have video capabilities as a safety measure to monitor patients with new

traumatic brain injury.

Spaces are programmed in accordance with Texas Administrative Code which meets CARF guidelines for self contained •

rehab unit which provides spaces for therapy services, social support services and spaces which allow and foster inclusion

of families in patient care.

Nursing Model of Care: • Will remain primary with 1 nurse and patient care assistant to a designated number of patients.

Medical Model: • Parkland will continue its mission of teaching residents and medical students. Changes in CMS guidelines,

physician shortages and the increasing acuity of hospitalized patients are driving the development of hospitalist programs,

increased use of midlevel providers, and more on-service time for existing attending physicians. The new space needs to

accommodate these clinicians 24/7. Provisions for designated available space for educational activities, offi ces and call

rooms will be allocated.

Future State


Rehabilitation / PM&RInpatient 17 bedsOut patient – OT, PT, STAlways full, waiting listTrauma and spinal cord injury

• Staf f• 24 Residents (10 at Parkland at any given time

• Wound care team: plastic surgeon, RN, PM&R

Services:• Inpatient acute rehab• Therapy in and out patient• Wound care-hydrotherapy

SNF if no be available patient may go there to wait

Transfer from inpatient unitReferred from:• Inpatient service:

Med/Surg / trauma• Acute rehab service-

consult from PM&R

Inpatient units, ICU’s

LTCF

SNF

Home

Shelter

While on the unit the following come to patient

While on unit patient may go to:• EEG• MRI/ imaging• Dialysis• Aphaeresis• Hydrotherapy• Clinic for procedure clearance• OR• Clinic• ICU• Medsurg unit

• Consulting MD• Chaplin• Students • Lawyers• Court officers• Health

department• Sheriff• Research RN• Biomed• Engineering• D/C RN for

medicine• Police• Jail Health• Volunteers• Family / visitors

• WCS• OT/PT/ST• SW• D/C planning• Rx.• Psych• Psychology• MRD• Dialysis• Radiology• Phlebotomy• Financial

counseling• Interpreter• Outside facility

liaison• School

Entry Points End Points

Transfer from inpatient unit

Sec3:35


The inpatient acute care rehab unit should be easily accessible to staff, materials management, visitors. •


will be programmed.

In the future state operating model many staff will be dedicated to specifi c units. Some adjacencies will be programmed into •

the new unit space.

The new space will accommodate phlebotomy and direct access to clinical lab and pharmacy via pneumatic tubes. Care •

coordinators and social workers will have space on the care units.

Consideration should be given to the following intuitive adjacencies when the building is stacked:•

-Medical / Surgical Acute Care patients requiring therapy services adjacent to Acute Care Rehab. Unit

-Clinical lab, blood bank, and pharmacy adjacency needs will be met with pneumatic tubes.

-Potable imaging, ECHO, EEG will be available bedside in the ICU’s and on the acute care units as necessary

Adjacency Diagram

FUTURE FLEXIBILITY:

A Universal Room Concept will be utilized to provide a fl exible, physical environment that supports varying acuity of patients •

and avoids multiple transfers.

Blocks or modules of rooms can be designated for specifi c acuity levels or disease populations. •

In the new hospital the rehab unit will be located adjacent to a medical surgical acute care unit that will allow the rehab unit •

to fl ex into the adjacent space.

It is envisioned that the rehab unit in the future may increase to 60 beds. •

The concept of a trauma institute is being considered. Organizing trauma services, from acute ICU to PMR as one organized •

service is being discussed.

Placement of the satellite gym in the unit core adjacent to the rehab unit will allow patients with rehab goals to be treated in •

one geographic area.


Sec3:36

Imaging

Pharmacy

Therapy / Hydro-therapy

OR

PT, OT, ST

InpatientRehab MRD

THIS FUNCTIONAL NARRATIVE IS ASSOCIATED WITH THIS SPACE PROGRAM:

Psychiatric Inpatient Unit•








Provide inpatient psychiatric care.•

Detox should be separate service.•

It is projected that PHHS psych inpatient unit will need to accommodate 6500 in •

patient days over the next 5 years.

It is anticipated that Northstar-managed medicade will increase referrals over •

the next years.


Currently the psych unit at PHHS accommodates 575 admissions annually. •

ALOS for patients is 9 days for a total of approximately 5000 inpatient days.

The average occupancy on the unit is 78%.•

The majority of the admissions are referred from the psych ED or the outpatient •

psych clinic.

All admissions are involuntary.•

The current psych unit is small and outdated. In a recent mock JCHAO it was •

identifi ed that the bathrooms were not compliant.

On the current unit there is a lack of visualization of patients.•

There is a lack of safety features in patient rooms.•

There is poor medication room set-up.•

There is a lack of AV monitoring for patients in seclusion.•


Model of Care:

All admissions will continue to be involuntary. •

There is need to separate detox from general psych.•

Functional Narrative - Psychiatric Inpatient Unit

Sec3:37

Space Program:

Unit Size: • Future confi gurations will be standardized and should allow nurse patient ratios to be divisible by 2-4-6. A


Nursing Unit Layout:• The use of single patient rooms will increase the footprint size of the patient care units, thus the space

design must maximize visibility, spatial relationships and reduce travel distances. In addition staff to staff communication via


Security: • Electronic surveillance or electronic access to the unit is requested as a patient safety measure. This is a locked

unit.

Electronic Environment: • It is envisioned that the new hospital will be electronic. It is presumed that all documentation,






accomplished by pneumatic tube where applicable.



Inpatient rooms: • All rooms will be private with bathrooms and roll in showers. A % of the rooms will have AV monitoring

capabilities for patient safety. All rooms will have locked space for patient belongings. All patient rooms will have bathrooms

with roll in showers. Isolation rooms: 2 are planned on the unit per request of PHHS staff.

Medication Administration:• Each unit will have a secure med room at a 1:18 ratio. This room will provide space for

medication storage and supplies for dispensing medications. In addition each patient room will be designed with a nurse

server. A system which utilizes medication distribution to a patient specifi c space reduces medication errors.








programs.




Sec3:38

Specialized Spaces:

Recreation / Dining: • A 720 NSF space is planned to accommodate seating for 30.

Dayroom / Lounge/ Quiet Room:• 320 NSF is planned this space will accommodate 10 seats.

OT Arts/Crafts: • This space is provided at 14 NSF per bed per TAC.

Psych Eval Exam Room:• (2) private exam rooms are planned.

Seclusion Rooms:• (4) seclusion rooms with video capabilities for patient safety are planned.

ETC: • 240 NSF are planned to accommodate ETC procedures. This space includes prep and treatment space.

Logistical and staff support spaces• for respiratory therapy, nutrition, phlebotomy are also programmed on the unit.



- Most admissions occur between 7pm

- Most discharges occur between 2pm

Staffi ng:

Staffi ng ratios may vary by unit the space should be divisible by 2-4-6.•


The Psych ED is the most important adjacency. A vertical adjacency is planned.•

It is envisioned that the psych unit will be located on the same horizontal fl oor as PMR and units caring for patients with •

rehab/therapy needs. This will provide easy and effi cient access for therapy staff to care for many of their patients on one

horizontal plane.

FUTURE FLEXIBILITY:

The increased number of beds 24 will accommodate anticipated future growth related to changes in the Northstar program.•

All inpatient rooms will be universal and sized to meet Texas Administrative Code – ICU requirements, to provide a fl exible, •

physical environment that supports the varying acuity of patients and avoids multiple transfers. Blocks or modules of

rooms can be designated for specifi c acuity levels or disease populations.

The plan for how the units are confi gured in the new building should allow for fl exibility across units to accommodate •

programmatic growth, changes in science, technology and disease management and fl uctuation in patient census.


Sec3:39


Inmate Unit Treatment Center•








The Dallas County Commissioners Court placed the responsibility for the health of •

the Dallas County Jail inmates on Parkland in March of 2006. State regulation

requires TB screening, medical, dental, mental health and the pharmacy components

for the care of inmates.1

Background / Current State:

•Currently inmates are cared for in the same spaces as the general population. •

•Although efforts are taken to segregate the inmates from other patients many •

times they are intermixed with the general patient population.

•This poses, both a security concern and a public relations issue, as patients •

feel uncomfortable being intermixed with inmates.

Parkland is working closely with the county jail to provide complementary •

services to inmates that cannot be provided on site at the jail.

The jail infi rmary and medical staff are simultaneously working to increase both •

the numbers and types of medical services provided at the jail to reduce

unnecessary transports of inmates to Parkland Hospital.

1 Parkland Hospital Website Jail Health. www.parklandhospital.com

Functional Narrative - Inmate Unit Treatment Center

Sec3:40


Model of Care:

The Inmate Treatment Center will provide a secure and segregated environment where inmates can receive acute care •

hospitalization, outpatient subspecialty care or urgent care that cannot be provided at the prison.

The inpatient part of the unit will be designed to accommodate patients who are too acutely ill to be cared for at the prison •

infi rmary, but who do not require ICU level care.

Patients who require ICU level care, obstetrical services or emergency care (levels 1-3) will have services provided in the •

main hospital.

It is envisioned that inmates will arrive through a Vehicular Sally Port. A secure holding area is planned to securely manage •

inmates who are waiting for an exam room to become available.

The unit should be located in close proximity to radiology as the unit will not have imaging capabilities.•

The unit should be designed with the same level of security as a prison. Individual patient rooms should be designed as •

cells, to safely secure patients and staff.

Space Program:

Security spaces•

-Vehicular Sallyport: A vehicular sallyport that can support 2 vehicles at a time is planned.

-Security / Control Station: This space is programmed to be 100NSF and should be located adjacent to the sallyport.

-Police workroom: This space is programmed at 252 NSF and will accommodate 4 computer workstations.

-Gun Lock-Up Room: This should be a secure space with internal secure gun lockers.

-Video Arraignment: A separate room with video communication is planned. This room is programmed at 80NSF and

should be designed to accommodate security personnel to be in the room, but not on video.

Prisoner Holding: • An open area providing full vision to all holding is planned.

Seclusion Room/ Detainee Holding: • Two (2) holding spaces one male and one female are planned. These spaces should be

minimally furnished and have bulletproof glass windows to enable inmate observation. Theses rooms should have audio and

video monitoring equipment and should be sound proof. These spaces should also be negative pressure.

Inpatient rooms:• The unit will include 12 secure acute care patient rooms. AV monitoring is requested for safety and

security.

Isolation rooms:• Eight (8) of the rooms will be negative pressure, to accommodate the large number of inmates with TB or

TB exposure.

Exam rooms• : The space will also include 14 general treatment exam rooms to accommodate outpatient examinations and

urgent care. It is planned that medical and surgical subspecialists will come to the inmate unit to see inmates rather than

have inmates travel to medical and surgical clinic locations.


Sec3:41


The Inmate Unit and Treatment Center should be in close proximity to the ED and imaging. •

Direct access to the outside vehicular Sallyport is necessary. •

Adjacency Diagram

FUTURE FLEXIBILITY:

Parkland Hospital leadership will continue to work collaboratively with the leadership and medical staff of the county jail to

continue to provide appropriate quality care to inmates.


Imaging

EDICU

OR

Inmate Treatment

Center

Obstetrics

Sec3:42


Apheresis / Central Dialysis Unit•








The Dialysis and Apheresis Programs at Parkland provides acute inpatient •

hemodialysis and apheresis to patients. Currently these services are provided in

two separate locations.

The Acute Dialysis Unit provides hemodialysis for stable inpatients. •

70% of the dialysis patients are scheduled and are hospitalized patients with •

end stage renal disease.

30% of the dialysis patients who require emergent hemodialysis treatments and •

enter the hospital through the ED.

Portable hemodialysis is provided bedside in the intensive care units. •


Currently there are 8 dialysis stations including one isolation room on the unit. •

The Apheresis unit at Parkland currently has 5 stations and at the present time •

maintains a low census.

Functional Narrative - Apheresis / Central Dialysis Unit

Sec3:43

Model of Care:

The ESRD population treated at Parkland is projected to continue to grow. •

The program will continue to be an inpatient acute dialysis program. •

Outpatients will be treated only on an emergency basis. •

The acuity of the patients who are dialyzed is extremely high. •

In many cases patients are too ill to be accommodated in a dialysis chair, thus the stations were programmed at 143 NSF to •

accommodate beds or stretchers rather than dialysis chairs.

All ICU rooms and a percentage of acute care rooms will be plumbed for dialysis, in order to accommodate patients who •

cannot be moved.

Space Program:

A Combined Apheresis Central Dialysis unit is planned for the new facility. •

Stations: • The unit will have a total of 18 stations, each is programmed at 143 NSF.

Isolation: • Four of these stations will be isolation rooms, and will accommodate patients with Hepatitis B-, per Texas

Administrative Code. These rooms do not require negative pressure or anterooms.

-Patients with tuberculosis, or another air borne pathogen, requiring negative pressure, will be dialyzed in an

isolation room on an inpatient unit.

-All ICU rooms and a percentage of acute care rooms will be plumbed for dialysis, in order to accommodate patients

who cannot be moved.


Service 2006 2012 2017 KHC Request -Inpatient Hospital

Dialysis Stations (including Bedside) 8 14 15 14 (10 regular, 4 isolation)

Apheresis 4

Dialysis Statistics 2006 2012 2017

Total Outpatient Maintenance Treatments/Initiations ** 2,334 3,315 4,239

Total Inpatient Treatments/Initiations (Main Department) 3,836 3,728 7,460

Total Treatments 6,170 7,043 7,460

Annual Treatment/Initiations per Station 771 503 497

Daily Treatments/Initiations per Station 3.1 2.0 2.0

** through 2006 outpatient treatments provided on an emergent basis only

Functional Narrative - Apheresis / Central Dialysis Units

Sec3:44


The unit is open 7 days a week and provides dialysis services from 6:00 AM until 4:¬00 PM, Monday through Friday and 8:00 •

AM until 4:30 PM on the weekends.


The dialysis / apheresis unit will be part of the inpatient hospital. •

The dialysis / apheresis unit should be located with a horizontal adjacency to the acute care inpatient unit where the majority •

of the nephrology patients are hospitalized.

This will allow a quick and safe transport of patients to and from the dialysis unit. •

The unit should also be in close proximity to the ICU to provide effi cient movement of staff and equipment between the •

dialysis unit and the ICU.

It is not infrequent that the code team is called to the dialysis unit, so close proximity to the ICU is preferred. •

30% of the patients dialyzed are emergent and present in the emergency department effi cient access to the ED is requested.•

Patient Acute Care

Unit

Dialysis / Apheresis

Patient ICUUnit

Patient goes from the acute care unit to the Dialysis unit for treatment

Trained staff provide service at the bedside in the ICU

Patient ED

Patient who meets emergent hemodialysiscriteria is emergently sent to the Dialysis unit. Depending on the patients status post –dialysis:•Returns to the ED and is discharged home•Admitted

Dialysis Future State


Sec3:45

Adjacency Diagram

FUTURE FLEXIBILITY:

In the new hospital Apheresis and Dialysis will be combined for maximum fl exibility.


Sec3:46

Acute Care Units - ESRD,

Neph.

EDICU Dialysis & Apheresis

Hemat-ology


Antepartum/Postpartum - 36 Bed Units•

Postpartum/Antepartum Core - 72 Beds•

Newborn Nursery – 24 Bassinets per Floor•

Women’s Offi ces - relevant to other women and infant services and programs, •

also.


Proven evidence-based design for inpatient units.•

Best practices for mother/baby couplet care, holding nurseries and high risk •

antepartum units.

Completed staff questionnaires that provided input on current and projected •

status.

Series of PHHS user group discussions resulting in recommendations and •

general consensus.

PWC- PHHS strategic planning documents that provided the quantity of patient •

rooms and supporting projections for patient care space.


Inpatient care of antepartum and postpartum women with obstetric acuities •

ranging from routine postpartum care to pregnant patients at risk of pre-term

labor with complicating factors such as diabetes, hypertension or substance

abuse.

Care of relatively healthy babies who are generally stable, near-term and term •

babies of gestational age ≥ 35 weeks and birth weights > 2,100 grams.

Discharge and breastfeeding classes provided in Spanish and other languages •

by educators; population is largely Hispanic.

Infant services range from routine care, tests including hearing assessments, •

procedures such as circumcisions, newborn pictures, if family requests them,

and follow-up care among other services.

March of Dimes Family support program and the Child Life Specialists provide •

classes about baby care and meet other educational needs.

Long-term antepartum patients are offered opportunities to participate in •

activities to offset the boredom and depression of hospitalization.

Teaching service that includes education of nurses, medical students, residents •

and many others through a variety of formal and informal programs.

Functional Narrative - Postpartum/

Antepartum and Newborn Nursery

Sec3:47


PHHS providers: • renown for utilization of midlevel providers and residents in the provision of care. Providers include

almost 80 employed obstetric/gynecology faculty along with a strong core of nurses and many other multidisciplinary staff

who provide care to a large volume of patients. Most of the providers are organized by whether they care for the baby or

mother and by acuity.

Lack of privacy:• inventory of 164 postpartum and 55 antepartum / postpartum beds is in multi-bed rooms mostly. A

two-bed room equates to four-bed ward when two babies and two mothers are in the same room. The newborn nurseries

are reported to accommodate 88 bassinets, excluding the nurseries designated for continuing care. The care is provided on

third, fourth and fi fth fl oors.

Varying unit sizes:• most inpatient units are sized between 26-29 beds each and rooms are a variety of sizes. Room sizes and

locations were identifi ed as bigger issues than unit sizes. Some of the postpartum beds are located remotely from the

newborn nurseries.

Complex patient placement practices: • mothers are placed on high risk versus low risk units for postpartum care, which is

driven by rotating residents and assigning different types of practitioners. In recent years, PHHS has made changes to help

smooth the placement so that poor utilization of some units and over-utilization of other units is less of a problem. A central

“bed czar” directs patient placement. Antepartum patients are clustered into a high risk unit and use other rooms fl exibly

when needed.

Admission process separates babies and moms:• most healthy babies born in labor and delivery go to the admission nursery

for the fi rst 3 hours (admitted, weighted, bathed, eye ointment, Vitamin K, Hep B vaccine). Then the baby goes to the

postpartum room to stay with mom or to be fed. The opportunity to keep mom and baby together during this time is limited

by facility and processes, and is a rare occurrence according to staff. When labor and delivery is very busy, PHHS reports

that baby admissions are delayed and the admission process is often extended or occurs ahead of the completion of complete

data entry required to set up medical records.

Discharge process impacts bed availability: • PHHS reports that discharges are sometimes delayed because pediatric nurse

practitioners (PNPs) are waiting for lab results, patients have not been seen by the Birth Certifi cate offi ce or fi nancial

services or patients are awaiting transport couriers. Delayed patient pick-up by family or friends creates back-ups in some

cases.


Model of Care:

Parkland made a commitment to move from a “hybrid” mother-baby couplet care to a full continuum in the new facility. This •

objective was confi rmed in user group meetings and is included as a premise in the previous PHHS operational plan. The

model was summarized in the planning meetings as:

- One nurse providing care to a mother and her baby and a philosophy that states we should not separate them unless it

is due to mother’s preference or clinically indicated… Not really only about babies always being in mom’s room, which

is another concept known as rooming-in.

Research indicates that mother/baby couplet care :•

- Supports continuity of care and infant development1

1 Alleva, E., A. Berry, and F. Cirulli. (2003) Early disruption of the mother-infant relationship: Effects on brain plasticity and implications for

psychopathology. Neuroscience and Biobehavioral Reviews 27: 73-82.

Functional Narrative - Postpartum/Antepartum and Newborn Nursery

Sec3:48

- Helps reduce communication errors between nursery and postpartum nurse (same nurse for mother & baby

- Enhances patient teaching / nurse, resident and PNP communication with patient; opportunity to teach while talking

and observe the family

- Promotes maternal-infant bonding

- Supports family-centered care and family satisfaction

- Improves lactation initiation and breastfeeding

- Enhances nursing and medical staff communication

Operational processes will be developed for babies to be with their mothers rather than returned to a nursery for routine •

care. When assessments cannot or should not occur in the same room with the mother, then the nursery will be available.

The challenge of this model will be changing the process where the provider goes to the patients individually rather than •

having the patients come to the providers. In addition to supporting the mother/baby relationship, targeted goals could

increase competence with the opportunity to be present for more of the care and fewer questions later.

Parkland will continue its mission of teaching residents and students and has long been ahead of many facilities in its use of •

midlevel providers. The continuation of this approach is assumed in light of potential CMS changes in resident coverage.

Provisions will be made for designated available space for educational activities, offi ces and call rooms.

Future Model of Care for Antepartum/Postpartum Units and Newborn Nursery


Sec3:49

Space Program:

Patient Rooms: 252 private patient rooms for antepartum and postpartum care:

Private, standardized universal rooms appropriately sized for all acuities to:•

-Support reductions in hospital acquired infection rates

-Improve privacy- HIPAA compliance

-Target the “sweet spot” for effi ciency and walking distance

Four distinct zones: mom, infant assessment, staff and family for postpartum rooms, although these areas may overlap. •

Antepartum rooms will be sized identically to postpartum rooms, even though they will not be set up for infant assessment. •

Ample number of gas and electrical outlets for both patients and work space with computer access in or just outside the •

room.

Handwashing sink for caregiver.•

Private bathrooms with showers, handheld shower hoses and shower seats (ADA). •

Windows on exterior wall with view of outside from each room. No viewing windows into patient rooms from corridor work •

stations for privacy reasons. These patients are usually not sick and requiring observation as with critical care units.

Family support space that includes daybeds or equivalent sleeping space, television, wireless internet access and lockable •

personal item storage.

Individually controlled lighting and temperature in patient rooms.•

Isolation rooms with different air handling and ante rooms, but with equivalent room confi gurations. An adequate number of •

negative pressure rooms with ante rooms will be designed per infection control recommendations and Texas codes. They

can be used for non-isolation patients, when appropriate.

Patient rooms designed with consideration of bariatric patients. Nationally, approximately one million (33%) of pregnant •

women are categorized as obese1. The percentage that would benefi t from lifts is to be determined. The hospital is

considering putting lifts in 25% of patient rooms in the new hospital.

Reception and Control

Each unit will include a concierge area at the main unit entry. For staffi ng effi ciency, this person might serve multiple roles •

including a greeter who will direct staff and visitors and oversee access to the unit.

Proximity to the clinical team area and the Health Unit Coordinator will be important. With the roll-out of the EMR the role of •

Health Unit Coordinators is likely to change in the future. The exact job description is still yet to be determined but could

include a variety of control and communication functions.

While control and security are critical issues, the plan is not to station a uniformed security offi cer at this location routinely. •

The intention is a design that supports safety as a priority and a fi rst impression of warmth and friendliness.

Public and Family Space:

Patient rooms will be large enough to accommodate family and visitors comfortably and will include a place for a family •

member or other designated support person to recline / sleep.

Waiting areas will be programmed on each unit to provide a space for family to wait if they are asked to leave a patient room. •

Quiet, active and child zones will be planned in each waiting area.

A small consultation room on each unit will serve as private places for members of the healthcare team to meet with •

families or patients away from the bedside.

1 S. Y. Chu et al, Association between Obesity during Pregnancy and Increased Use of Health Care, The New England Journal of Medicine,

April 3, 2008


Sec3:50

Patient Unit Layout (including holding nurseries)

Inpatient postpartum and antepartum services will be provided on seven 36-bed units, totaling 252 beds plus a 28 bed •

gynecological unit.

Optimal unit layout includes:•

- Less centralization

- Moves staff areas to patients

- Moves support areas to patients

- Reduces walking distance due to increased geography of larger private patient rooms

One of the 36-bed units will be dedicated to antepartum care and does not require a holding nursery, unless the unit is built •

for future fl exibility to accommodate postpartum patients.

When Parkland’s antepartum needs exceed the capacity of one unit, a second 36-bed unit of mixed antepartum/postpartum •

rooms will be provided for fl exibility. Ideally, patient placement would result in clustering antepartum patients together and

away from the postpartum mothers and nursery. The dedicated antepartum unit could share a fl oor with the gynecology

inpatient unit or share with a mixed antepartum / postpartum unit.

Assuming one antepartum and one fl exible ante/postpartum unit, the remaining fi ve 36-bed units will function primarily for •

postpartum and newborn care and will be considered “mother/baby” units with a central holding nursery located in the core

between them.

Each set of two units on a fl oor will have common family and public support space and will share some staff support areas •

such as conference space.

PHHS plans to continue organizing patient placement by acuity, but will have the fl exibility to place any patient in any room •

since all rooms will be standardized. The exception will be isolation rooms that will have different air handling, ante rooms

and other features. An adequate number of negative pressure rooms with ante rooms will be designed per infection control

recommendations and Texas codes.

Holding nurseries will contain a total of 72 bassinets divided into 24 bassinets per fl oor in adjacent rooms of twelve •

bassinets, depending upon layout and approval by the state agency.

Texas Administrative Code (TAC) stipulates that a service must have holding nursery bassinets at a minimum ratio of 50% of •

postpartum beds and each nursery shall not have more than 16 bassinets per room.

Bassinet space is planned in every postpartum room in addition to the holding nursery. •

While the nursery ratio does not apply to antepartum beds, a holding nursery will be required for any fl oor with a mix of •

antepartum and postpartum beds.

Codes are not followed in the program because PHHS determined that 50% of postpartum beds results in excessive nursery •

space due to the combined percentage of 24 hour rooming-in and NNICU babies. Two nurseries with 12 bassinets each is

programmed per fl oor (approximately 33% of 216 postpartum beds). A PHHS study will be needed to support an application

for variance or exception from TAC.

“Sick nursery” services will be consolidated with the NNICU and included in the total NNICU bed count for Level II and III •

care.

Team Work Stations/Charting:

Assumption that electronic medical records will be implemented when this facility opens. •

Computers will be provided with a decentralized approach in locations outside the patient room and dispersed throughout •

the unit.

Going live with electronic medical records will result in bedside or near bedside charting of certain information such as •

admission assessment and vital signs. Using the computer for all of the charting will be a signifi cant change for current

staff, but could provide an opportunity to further support mother/baby couplet care prior to moving into the building.


Sec3:51

Provider Rooms:

Two workrooms will be provided on each 36-bed unit with one for providers caring for moms and one for providers caring for •

babies. In addition, multi-purpose midlevel practitioner rooms will be provided where appropriate.

General Support Space:

Separate onstage and offstage functions and patient, public and logistics traffi c (both horizontal and vertical). •

Space to support “green” practices such as recycling.•

Equipment, supplies, and documentation tools will be located to promote effi ciency by reducing travel distances within the •

units.

Horizontal pathways and vertical transporting systems designed to reduce the physical demand on personnel servicing •

multiple units and departments.

Separate onstage and offstage functions to support patient, public, and logistics traffi c.•

Medication Administration:

A secure medication room will be provided at a ratio of 1:18 beds. This room will provide space for medication storage and •

supplies for dispensing medications. Pharmacy will be reducing the quantity of satellite pharmacies, including the labor and

delivery satellite, which will be replaced by direct service from the Main Pharmacy. Medication delivery will utilize

automated dispensing machines (Pyxis) with medication stocking by pharmacy. Specialty or emergency delivery of products

will be accomplished by pneumatic tube. From a best practice perspective, a system which utilizes medication distribution to

a patient specifi c space reduces medication errors.

Disaster Preparedness:

Design should support ability to accommodate disaster preparedness.•

Equipment:

Supply and medication rooms will be standardized and conveniently located on each fl oor.•

There will be an adequate number of Pyxis machines conveniently located to patient care areas.•

Locked space within the patient care area for patient specifi c supplies and medications (TBD).•

Central Logistics staffed 24/7 will accommodate equipment that can be obtained within a 60 minute window. (Planned at •

10sq foot per patient. Additional storage space at 10sq foot per patient will be on the fl oor).

Lockers, Lounges, Offi ce and Conference Space

Suffi cient space is provided for allied health, MD, students and other caregivers on each unit. Providing adequate space and •

making PHHS attractive to nursing students, physicians and other is an important consideration for future success.

Conference space is provided in the core between two units and could be provided on every other fl oor if required.•


24 hours a day- 7 days a week•


Sec3:52

PHHS Utilization / Volumes:

The PWC data indicated that approximately 19,400 antepartum and postpartum discharges were projected for 2017, given 17,654

deliveries. The PWC projections indicated a need for 243 beds for postpartum and antepartum and rounded the beds to 7 units of

36 beds (252 beds). PWC projections assumed a 65% average occupancy rate and used a normative model for prediction.

Staffi ng:

Primary nursing care model with 1 nurse to 4 couplets generally (RN with PCA) plus nursery staff.•

Nurses back each other up and each nurse “reports off” to another nurse. •

Charge nurse has assignment.•

RNs do not usually leave the unit due to “no time” and 7a-7p cafeteria is closed.•

Techs handle supplies with supply and medical Pyxis on each fl oor.•

PNPs work in the newborn nurseries, all postpartum units, attend deliveries and perform circumcisions.•

Almost 40% of postpartum nurses have 10 or more years of experience and may not have had the opportunity to work in •

other environments with this model of care. Transition, orientation, dealing with fears and change management will be

critical for success.

Service FY03 FY04 FY05 FY06 Annual Change 03-06

Total Change 06-12

FY12 Total Change12-17

FY17

Antepartum

Discharges 300 254 288 325 1.7% 1.9% 341 1.0% 348

Days 8,818 9,706 9,477 9,068 .6% 9,660 11,146

Average Daily Census 24.2 26.6 26.0 24.8 .6% 26.5 30.5

ALOS 29.4 38.2 32.9 27.9 -1.0% 1.5% 28.3 2.8% 32.0

Postpartum

Discharges 17,252 17,385 17,433 17,766 .6% 1.9% 18,647 1.0% 19,021

Days 38,998 38,042 36,729 37,773 -.6% 40,240 46,430

Average Daily Census 106.8 104.2 100.6 103.5 -.6% 110.2 127.2

ALOS 2.3 2.2 2.1 2.1 -1.2% 1.5% 2.2 2.8% 2.441

Women’s and Infants’ Specialty Hospital Services (PWC)



Sec3:53


Postpartum rooms and newborn holding nurseries will be on the same fl oor resulting in a “mother/baby” unit.•

Postpartum and antepartum units should be easily accessible to staff, materials management and families. Designated •

elevators for staff, patients, families, visitors and supplies to decrease travel time, improve effi ciency and patient safety will

be designed.

Most patients will arrive on these units from the Labor and Delivery fl oor, requiring attention to designing “off-stage” paths •

among these units.

Midlevel provider rooms should be convenient to these patient units.•

Adjacency Diagram

ICU

Transport after delivery other than

in L&D

Labor and Delivery

Home

Other: (ICU, Transport, Jail, Morgue)

Patient flow from AP/PP unit:

Newborn Nursery

Admin and Staff Support (eg, call rooms, offices, lounges, conference,

lockers)

Clinical Support, Family Support and Ancillary

Services

Antepartum or Postpartum Inpatient Unit

Antepartum/Postpartum Unit and Newborn Nursery Internal Functional Adjacencies and Flow

Infant & Lactation Follow-up

FUTURE FLEXIBILITY

Projected growth is expected to be gradual, resulting in the consideration of shelling thirty-six rooms of the 252 rooms. •


Sec3:54


GYN - GYN/ONC - URO/GYN Patient Care Unit - 28 beds•

GYN - GYN/ONC - URO/GYN Patient Care Unit Core•

GYN Chemotherapy / Infusion Therapy •


Proven evidence-based design and best practices for inpatient units.•


status.


general consensus.




Inpatient gynecology services for general gynecology, uro-gynecology and •

gynecology/oncology.

Adjacent chemotherapy/infusion unit accommodates patients who require these •

therapies, most of whom were gynecology/oncology patients in the inpatient

unit.

Wide range of acuity from overnight uro-gynecology care to seriously ill cancer •

patients.

Patients with fetal losses who do not want to be on the postpartum or •

antepartum units.

Women with brachytherapy such as thyroid cancer patients (lead lined rooms).•

Participation in research projects in concert with University of Texas •

Southwestern Medical School.

Teaching service that includes education of nurses, medical students, residents •

and many others through a variety of formal and informal programs.

- In total during their training, residents spend 16 months on the Parkland

Hospital Gynecology Service and some of their time is spent on this unit in

addition to clinics and surgery.

Background / Current state:

Current inpatient unit includes approximately 22 beds on 4 West. One patient •

room was converted to space for patient / families.

Lead lined for radiation therapy shielding – occasionally male, but mostly female •

(estimate less than 150 per year).

General consensus in women’s services that 4 West works well and patient •

satisfaction is noted for its consistently high ratings; perception of a collegial

culture of multi-disciplinary providers and other staff.

PHHS gynecological service ranks in the top 15 in US News and World Report •

consistently.

Bed availability has not been a frequent issue due to a typical census of 12 to 16 •

patients, recently.

Functional Narrative - Gynecology and Chemotherapy/Infusion

Therapy Units

Sec3:55

Central team workstation is a feature reported as valued by the GYN user group.•

Chemo/infusion clinic is undersized and converted patient rooms that do not lend themselves to optimal function: crowded •

and do not support confi dentiality.

Care is provided by multi-disciplinary team of providers to support the diversity of diagnoses and acuities.•

Staff are cross-trained for 4 North and 4 West, excluding gyn-oncology.•


Model of Care:

Twenty –eight room inpatient unit and a fi ve bed therapy unit will be provided for gynecological care in the new facility. •

Model will continue to be based on a multi-disciplinary and highly collaborative environment for the delivery of care.•

Focus will include a continuum of care for patients, which is especially important to cancer patients and their families.•

Space Program:

Patient Rooms

Private, standardized universal rooms appropriately sized for all acuities that:•

- Support reductions in hospital acquired infection rates

- Improves privacy- HIPAA compliance

-Targets the “sweet spot” for effi ciency and walking distance

- Space for patient, staff and family, though these areas may overlap. (Antepartum, postpartum and gynecology rooms

sized uniformly).

Ample number of gas and electrical outlets for both patients and work space with computer access in or just outside the •

room.

Handwashing sink for caregiver.•

Private bathrooms with showers, handheld shower hoses and shower seats (ADA). •

Windows on exterior wall with view of outside from each room. No viewing windows into patient rooms from corridor work •

stations for privacy reasons. These patients are usually not sick and requiring observation as with critical care units.

Family support space that includes daybeds or equivalent sleeping space, television, wireless internet access and lockable •

personal item storage.

Individually controlled lighting and temperature in patient rooms.•

Isolation rooms with different air handling and ante rooms, but with equivalent room confi gurations. An adequate number of •

negative pressure rooms with ante rooms will be designed per infection control recommendations and Texas codes. They

can be used for non-isolation patients, when appropriate.

Chemotherapy/Infusion Therapy Unit

4 treatment / observation rooms plus one isolation treatment room.•

Point of care testing on unit and staff work and support space separate from the inpatient unit.•

Space for secured patient/family belongings needs to be located in each bay and in the private infusion room.•

Internet access at each station.•

Natural light would be benefi cial to patients.•

Functional Narrative - Gynecology and Chemotherapy/Infusion Therapy Units

Sec3:56

Patient Unit Layout

By locating the gynecology inpatient services and the chemotherapy/infusion therapy next to each other, staff, space and •

operational effi ciencies will be realized. In addition, the proximity is considered a strong patient satisfi er because of the

culture and familiarity that has been created in these units.

Would like a distinct way to identify and locate women’s services and include this space as part of the comprehensive •

services for women offered by PHHS.


Concierge area at the main unit entry. For staffi ng effi ciency, this person might serve multiple roles including a greeter who •

will direct staff and visitors and oversee access to the unit.

Proximity to the clinical team area and the Health Unit Coordinator will be important. With the roll-out of the EMR the role of •

Health Unit Coordinators is likely to change in the future. The exact job description is still yet to be determined but could

include a variety of control and communication functions.

While control and security are critical issues, the plan is not to station a uniformed security offi cer at this location routinely. •

The intention is a design that supports safety as a priority and a fi rst impression of warmth and friendliness.


Patient rooms will be large enough to accommodate family and visitors comfortably and will include a place for a family •

member or other designated support person to recline / sleep.

Waiting area will provide a space for family to wait if they are asked to leave a patient room. Quiet, active and child zones will •

be planned in the waiting area.

Consultation room will serve as private place for members of the healthcare team to meet with families or patients away •

from the bedside.

Patient Education Room / Therapies / Activities Room for long term patient activities; located within GYN unit core and not •

fl oor core unless remainder of fl oor becomes GYN (separate room eliminated and function to occur in conference room or in

waiting area).

Family consultation room for private meetings away from the patient’s room.•



Computers will be provided with a decentralized approach in locations outside the patient room and dispersed throughout •

the unit.

- Multidisciplinary provider space for attendings, consultants, fellows, residents and other providers could be combined

or co-located with team room and zoned.


Separate onstage and offstage functions and patient, public and logistics traffi c (both horizontal and vertical) will be

programmed.



units.




Sec3:57

Medication Administration:

Two secure medication rooms will be provided (ratio of 1:14 beds). This room will provide space for medication storage and •

supplies for dispensing medications. Medication delivery will utilize automated dispensing machines (Pyxis) with medication

stocking by pharmacy. Specialty or emergency delivery of products will be accomplished by pneumatic tube. From a best

practice perspective, a system which utilizes medication distribution to a patient specifi c space reduces medication errors

and is being considered.



Equipment


There will be an adequate number of Pyxis machines conveniently located to patient care areas.•

Locked space within the patient care area for patient specifi c supplies and medications.•

A Central Storage Garage staffed 24/7 will mange equipment that can be obtained within a 60 minute window. This will be •

sized at 10 square feet per patient. Additional storage space at 10 square feet per patient will be planned on the fl oor.

Lockers, Lounges, Offi ce and Conference Space

Suffi cient space is provided for allied health, MD, students and other caregivers on each unit.•

Conference space is provided in the core between two units and could be provided on every other fl oor if required.•



Majority of gyn surgeries are scheduled •

Utilization / Volumes:



Total Change 06-12


FY17

GYN and GYN Oncology

Discharges 1,502 1,625 1,583 1,627 1.7% 1.9% 1,658 1.0% 1,674

Days 4,883 4,983 5,244 5,331 1.8% 5,329 4,520

Average Daily Census 13.4 13.7 14.4 14.6 1.8% 14.6 12.4

ALOS 3.3 3.1 3.3 3.3 .2% -1.9% 3.2 -3.8% 2.7



Staffi ng:

Varying levels of acuity and associated staffi ng ratios, typically 1 nurse to 4 patients on the inpatient unit.•

Sec3:58


The following diagram depicts internal functional adjacencies and future fl ow. The diagram is distinguished from the graphic

analysis of the program (GAP), which identifi ed the specifi c rooms and areas included in the program.

Key functional adjacency requirements include:

Adjacency between the chemo/infusion therapy unit and inpatient unit.•

Receive patients from surgery in a convenient path.•

Co-located with other women’s services for identity and continuity of care.•

Consider relationship with other oncology services, preferably adjacency, if medical/surgical tower is connected to women’s •

tower.

Adjacency Diagram

FUTURE FLEXIBILITY:

The proposed 28 bed unit will provide additional capacity beyond recent 65 – 70% occupancy of the 21-22 available beds. •

Should future strategic planning result in a successful campaign that signifi cantly increases patient needs beyond the 28 •

beds, then ideas for additional expansion include: 1) expanding into the adjacent 36 bed women’s unit, which will be

potentially shelled space in the short-term although it is intended for birth service expansion at this time; and 2) converting

the chemo/infusion area to rooms resulting in up to a 36 bed unit.

As with many hospitals, PHHS gynecological services are a sliver of the total inpatient services but have higher potential •

growth for same day surgery and outpatient services.

Future fl exibility to increase outpatient and same day gynecology services is being planned at hospitals and ambulatory •

surgery centers throughout the US and is another consideration for PHHS. The Advisory Board Company report on women’s

health identifi ed a latent demand in the US for uro-gynecology services and an expected steep escalation in the future,

especially for minimally invasive procedures 1.

1 Health Care Advisory Board Innovations Center Staff, Future of Women’s Services: Strategic Forecast and Investment Blueprint The Advi-

sory Board Company • Washington, D.C. 2005


Surgery

ICC/ Clinic/ MoncriefReferral/ED

Other Medical Admission or ICU

L&D(eg, fetal demise)

GYN Inpatient Unit Internal Functional Adjacencies and Flow

Home


Patient flow from GYN unit:GYN Chemo/Infusion Unit


lockers)


Services

GYN Inpatient Unit

Sec3:59


Labor and Delivery Unit•

Labor and Delivery Administration•

Obstetric Triage•

Women’s Offi ces - relevant to other women and infant services and programs, •

also.


Proven evidence-based design for universal labor/delivery/recovery (LDR) •

model; elimination of traditional delivery rooms; and appropriately sized patient

rooms and support space.

Identifi ed best practices related to mother/baby recovery, triage process •

integrated with “labor and delivery”; bolstered identity for the service line;

standardized support spaces when appropriate; and streamlined operations.


status.


general consensus.

PWC- PHHS Strategic Planning Documents that provided the quantity of patient •



“Labor and Delivery” includes triage, obstetric observation, vaginal and •

Cesarean births, extended high risk obstetric care and elective obstetric

surgeries.

Generally, patients in “labor and delivery” are pregnant women and their babies •

greater than 24 weeks gestational age who reside in the region, with some

women from the hospital’s 30 county referral area.

Obstetric services extend beyond birth to outpatient obstetric observation; •

elective and non-elective obstetric procedures: tubals, cerclage, placenta

retention, chronic and short-term antepartum care and terminations for genetic

issues and other reasons.

PHHS provides a comprehensive scope of perinatal services and is a national •

leader in this fi eld. The service is further described as:

Second largest volume birth service in the country.•

Largest volume public hospital birth service. •

Strong academic mission for obstetrics including:•

- Approximately 75 - 80 OB/GYN residents and maternal fetal medicine

fellows.

- Known for team of physicians with strong ties to Parkland who update the

premier textbooks on obstetrics and gynecology, Williams Obstetrics and

Williams Gynecology.

- School of nurse midwifery.

- Nurse extern program.

Functional Narrative - Labor and Delivery Unit

Sec3:60

- Support of many other teaching initiatives from high school students to maternal-fetal medicine fellowships.

Research and studies including recently documented success of Parkland in reducing the preterm birth rate consistently •

during the past 15 years in contrast to a national climb. PHHS has both a lower overall rate and decreased disparity in

preterm birth rates between white women and racial ethnic/minorities in comparison to national norms.1


Organization of services: • birth services are divided into three distinct units that support different levels of medical acuity

and provider coverage:

- Highest acuity labor and delivery unit is staffed by faculty and residents (L&D West).

- Two lower acuity units are staffed by certifi ed midwives, residents and faculty (L&D East and 4 South-South).

- Cesarean / operating rooms are not centralized and are located on two of the three units.

- Grouping obstetric patients by acuity is a common practice in regional perinatal centers with high birth volume in their

labor and delivery units and seems to work well with appropriate design.

Obsolete facilities and ineffi cient patient fl ow: • current labor and delivery facilities do not meet today’s minimum local and

national norms and facilities are in need of full replacement. The model requires an assembly-line approach and greater

movement of obstetric patients from room to room than experienced at many other hospitals. An insuffi cient number of

LDRs and the relative isolation of the three units results in patient placement practices that are sometimes based on

creative “work arounds”, especially when census is high or low.

Minimal fl exibility and standardization of rooms: • patient beds are located in rooms of various sizes and capacities with

minimal standardization. The complement of rooms includes but is not limited to 20 beds for labor and induction, 14 LDRs, 4

traditional delivery rooms and 7 Cesarean operating rooms.

Family-centered care impeded:• many of the patient rooms are not sized to keep mother and infant together when

appropriate nor do they provide suffi cient space for other family members - two basic premises of family-centered care. All

rooms are not private. Family waiting space and toilets are limited, also.

Perceived disproportionate clustering of rooms:• a centralized, traditional nurses’ station on the highest risk labor and

delivery unit was observed to be noisy and crowded on several occasions. The lowest risk unit was observed to be quiet and

served fewer patients. Staff confi rmed that these situations were not unusual. Average occupancy of the individual units

was perceived to be disproportionate, but data were not analyzed to confi rm the frequency of this situation.

Undersized staff support space: • staff spaces are undersized from break rooms to the number of staff toilets, computer

work areas and the size of locker rooms. The location of space was an issue for staff, also. On one of the units, staff had

converted what appeared to be a closet to a break room near the nurses’ station. A larger lounge was nearby, but some staff

preferred to take a break in the tiny room rather than walk a few more yards to the lounge. This preference was explained

anecdotally as a social preference and the desire to stay as close as possible to the nurses’ station. During tours, areas for

physicians including the anesthesia ready room were observed to be crowded.

1 Leveno et al, Decreased Pre-term Births in an Inner City Public Hospital, Obstetrics and Gynecology, ACOG, VOL. 113, NO. 3, MARCH 2009,

578-584.


Sec3:61


Model of Care:

Care models will continue to range from minimal intervention with certifi ed nurse midwifery based care for a low risk •

population to a medical model for high risk obstetric patients.

Family-centered care is emphasized as a basic guiding principle for all care.•

Parkland will continue its mission of teaching residents and medical students and has long been ahead of many facilities in •

its use of midlevel providers. The continuation of this approach is assumed in light of potential CMS changes in resident

coverage. Provisions will be made for designated available space for educational activities, offi ces and call rooms.

Space Program:

PHHS will continue to serve obstetric patients and their families in an expanded facility that addresses the defi cits described •

as the current state. The facility will support a model of care that results in less patient movement through utilization of

LDRs for most vaginal births, less physical segregation of units and more appropriately sized operating rooms. Features

include:


Concierge/control area at the main unit entry. •

For staffi ng effi ciency, this position may be staffed by someone serving multiple roles including a greeter who will direct staff •

and visitors and oversee access to the unit. Proximity to the clinical team area and the Health Unit Coordinator will be

important. With the roll-out of the EMR the role of Health Unit Coordinators is likely to change in the future. The exact job

description is yet to be determined, but could include a variety of control and communication functions.


Waiting areas on each unit will provide a space for family to wait if they are asked or want to leave a patient room. •

Patient rooms are sized large enough to accommodate family and visitors comfortably and should help decrease waiting •

rooms needs.

Small consultation rooms on each unit, which serve as private places for members of the healthcare team to meet with •

families or patients away from the bedside.

Patient Rooms

Forty-Three (43) Labor/Delivery/Recovery (LDR) Rooms: •

- More than triple the current number of LDRS (from 14 to 43 or 48 with ECU beds) and appropriate space for

practitioners, supplies, equipment and maneuvering.

- Twelve-bed clusters of LDRs connected to each other and the Cesarean ORs. Could be sub-divided into groupings of

six LDRs (e.g., Northside Hospital example reviewed).

- All private, standardized universal rooms appropriately sized for varying acuities of vaginal births to replace

semiprivate and multi-patient labor rooms.

- Four distinct zones: mom, infant, staff and family. Patient space includes dedicated space for infant resuscitation/

stabilization in the room, in addition to a resuscitation space located near the suite for babies too unstable to be

transported to the NNICU or Children’s Hospital immediately after birth. More LDR space is planned for

practitioners, patients, families, equipment and supplies.

- Ample number of appropriately placed gas and electrical outlets and work space with computer access.

- Handwashing sink for caregiver in each room.


Sec3:62

- Private bathrooms with showers, handheld shower hoses and shower seats (ADA).

- Windows on external wall with view from each room.

- Family support space that includes daybeds or equivalent, wireless internet access and lockable personal item

storage.

- Individually controlled lighting and temperature in patient rooms.

- LDR model is the prevalent design for non-operative, vaginal births and replaces traditional individual labor and

delivery rooms.

Five (5) Extended Care Rooms•

- Sized the same as LDRs for fl exibility and contiguous with both the LDRs and the post-anesthesia recovery area.

- For high acuity patients needing more direct observation and proximity to a higher level of care and resources than

available in antepartum and postpartum (e.g., post HELLP syndrome).

- Operates similarly to a high level “obstetrics ICU step-down” except for patients needing intubation or other services

that are better provided in an adult ICU.

No Traditional Delivery and Labor Rooms: •

- Program replaces traditional delivery room design since hospitals in the US have been phasing them out during the

past 30 years for new construction.

- Most hospitals use either a Cesarean operating room or the LDR equipped for high risk vaginal births instead of an

“in-between” traditional delivery room that does not quite meet the standards of either of these other options. Texas

requires a minimum of one delivery room, and an LDR is interpreted as meeting this requirement typically, although

code language is unclear on this point. Codes clearly indicate that LDRs may be substituted for the requirement of

traditional labor rooms and recovery rooms.

- Health Facility Guidelines being proposed for 2010 and used or referenced by 40+ state regulatory agencies (Texas has

its own) are moving toward elimination of facility guidelines for traditional delivery and labor rooms in new

construction.

- This “best practice” was highly recommended and became a planning assumption, although not without some

concerns and questions from user group members about converting to this approach.

Nine (9) Cesarean/Obstetric Operating Rooms: •

- Large, central Cesarean/Obstetric OR suite will be positioned for convenient access from all LDR clusters and the pre

and post operative areas to work effectively and safely.

- Cesarean/OR rooms are programmed at uniform size of 624 net square feet, which is consistent with standard

operating rooms in the main OR.

- Cesarean birth rooms will allocate dedicated infant resuscitation space within the room.

- Separate infant resuscitation room for special cases will be provided separately.

- Large clean core will be provided in this suite; ORs will be served by central sterile with provision for stat needs rather

than maintaining a sterile processing satellite.


Sec3:63

Eight (8) Pre-Operative and Ten Post-Operative Rooms•

- Eight pre-op rooms for simultaneously scheduled patients assuming at least one of the nine ORs will be available for

stat Cesareans. Pre-op areas could be three hard walls or a room similar to recovery for fl exibility.

- The pre and post operative rooms will be located adjacent to the operating rooms and will be within the Labor and

Delivery Unit. The Obstetric OR suite will be separate from the Main OR, but will be located conveniently on the same

fl oor as the Main OR, which includes GYN ORs.

- Rooms will be sized for mother/baby recovery in the same room as an option when appropriate, for the following

reasons.

- Promotes breastfeeding and bonding

- Supports reductions in hospital acquired infection rates by eliminating multiple bed rooms

- Improves confi dentiality-HIPAA compliance

- Supports privacy for sensitive situations such as fetal demise, terminations or women who want privacy for

bonding. Use of glass and curtains provide privacy options while maintaining staff line of sight.

Eight (8) Observation Rooms•

- The eight observation rooms will be sized for easy conversion to four LDR’s, if needed. Observation rooms are

programmed at 180 nsf and LDR’s at 360 nsf.

- Observation will occur in private rather than open multi-patient rooms (bays) for fl exibility and family-centered care.

- Observation rooms are being considered in the PHHS strategy to shell some rooms initially.

- Obstetric observation rooms should be in close proximity to LDRs and other areas within Labor and Delivery.

Other Patient Room Considerations

Isolation Rooms •

- An adequate number of negative pressure rooms with ante rooms will be designed per infection control

recommendations and Texas codes. They can be used for non-isolation patients, when appropriate.

- Exceptions to standardized LDRs due to different air handling and ante rooms, but with equivalent room

confi gurations. Isolation rooms are included in the LDR count.

Bariatrics•

- Patient rooms must be designed with consideration of bariatric patients. Nationally, approximately 33% of

pregnant women are categorized as obese. Lifts are being planned in 25% of patient rooms in the new

hospital and are recommended in this area.

Patient Unit Layout:

Units confi gured to maximize visibility, spatial relationships and support a “lean” approach to care delivery. Larger •

and more patient rooms will increase the footprint size of the units so that layout will need to support reduced travel

distances.

Less isolated confi guration than the current segregation of the three obstetric delivery units. Operational planning and •

further studies need to be completed regarding the assignment of patients and staff to specifi c LDR clusters based on

provider teams, acuity, projected volumes and other factors. Flexibility in design will support the fact that these

variables tend to fl uctuate over time. Centralized ORs will increase fl exibility as opposed to the current split into two

separate suites in different locations.

The functions of the current Women’s Elective Surgery Unit (WESU) will be incorporated into separate track for pre-op •

fl ow for scheduled Cesareans and other elective procedures.


Sec3:64



Computers will be provided with a decentralized approach and dispersed throughout the unit.•

Hybrid approach to work space that includes both centralized and decentralized work stations. •

- Moves staff areas to patients

- Moves support areas to patients and materials to staff

- Helps address walking distance due to increased geography of larger footprint:

- Targets the “sweet spot” for effi ciency and walking distance:

- Decentralized nursing stations with touchdown places for team collaboration

- Staff support areas less than 20 feet in distance from nurse work area

- Physician workrooms and teaching spaces

- Peer line of site-teaming

- Fosters effi ciency and way-fi nding

- Design of horizontal pathways and vertical transporting systems reduce physical demand on personnel

servicing multiple units and departments.

Support of staff to staff communication via advanced technology. •


Separate onstage and offstage functions and patient, public and logistics traffi c (both horizontal and vertical) will be •

required.



units.



Medication Rooms:

LDRs and the OR suite will have secure medication rooms. These rooms will provide space for medication storage and •

supplies for dispensing medications. Pharmacy will be reducing the quantity of satellite pharmacies, including the labor and

delivery satellite, which will be replaced by direct service from the Main Pharmacy and the satellite pharmacy in the Main OR

suite. Medication delivery will utilize automated dispensing machines (Pyxis) with medication stocking by pharmacy.

Specialty or emergency delivery of products will be accomplished by pneumatic tube.



Equipment and Supply Storage:


Adequate number of Pyxis machines conveniently located to patient care areas.•

Locked space within the patient care area for patient specifi c supplies and medications.•

Central Storage Garage staffed 24/7 will mange equipment that can be obtained within a 60 minute window. This will be sized •

at 10 sq foot per patient. Additional storage space at 10 sq foot per patient will be planned on the fl oor.


Sec3:65

Staff Support:

Lockers, Lounges, Staff Toilets and On-Call Rooms will be provided on this fl oor. Provider rooms, offi ces and Learning Resource

Center will be provided for women and infants’ services; location to be determined during design.



Scheduled procedures peak on Monday, Tuesday, Thursday and Friday mornings. Most patients arrive between 6 and 7 am, •

and scheduled procedures are not staggered throughout the days. Inductions are typically scheduled to start at 8 am and 8

pm.

Utilization/Volume:

To see if the projections are on track to achieving projected volume so far, the recent twelve months of utilization data were

reviewed. The deliveries appear to be tracking lower than projected for the 2006 Master Facility Plan, although there may be

slight variation when comparing fi scal and calendar years and straight-line growth is usually unrealistic. FY 2008 volume was

estimated to be 16,787 with this model and actual volume was 15,528 deliveries for CY 2008.

In addition to these volumes, PHHS reported that for every inpatient in “labor and delivery” there is slightly more than one

outpatient who has a labor assessment, short term observation or other need, but is not admitted. These patients would use the

triage or observation rooms.

Parkland Health & Hospital System

WISH Division

CY 2008 Statistics

CY 2008

Deliveries 15,528 •

NICU Admits 1,381 •

Antepartum Admissions 2,680 •

Provided by Paula Turicchi, Sr VP, Women & Infants Specialty Health 1/2009



Total Change 06-12


FY17

Labor & Delivery

Deliveries 15,796 15,726 15,811 16,489 .9% 1.9% 17,306 1.0% 17,654

C Section Rate 25% 26% 26% 26% .8% 15.4% 30% NA 30%

L&D Triage 21,293 21,403 20,992 21,140 -.1% -2.5% 20,612 -1.5% 20,302

Elective Surgery

Total Procedures 2,632 2,794 2,939 30.6% 1.9% 2,995 0.3% 3,004



Sec3:66


Staffi ng:

Currently there are approximately 130 RNs and 18 LVNs plus aids, coordinators and other employees in L & D (50 FTEs per •

day shift), according to a questionnaire completed by PHHS.

Staffi ng ratios vary widely based on acuity from 1 nurse:1 patient for delivery, 1:2 for inductions and up to 1:4 for other •

activities.


The following diagram is intended to serve as a tool to clarify internal functional adjacencies and future fl ow for “Labor and

Delivery”. The diagram is distinguished from the graphic analysis of the program (GAP), which identifi ed the specifi c rooms and

areas included in the program.

The diagram assumes the fl ow of an “established patient” who has seen a practitioner for prenatal care one or more times •

and has been informed about how to access Parkland’s “Labor and Delivery” unit.

Majority of established OB patients will be expected to enter through the street level birth service entrance, although •

exceptions are expected. Some women will arrive in the ED if they were in accidents or arrived by ambulance or helicopter.

Some pregnant pts may be referred from clinics or ICC directly to L and D. Patients will be directed to one of two places

upon entry: triage or pre-op for scheduled procedures. Some patients may pass through triage directly to an LDR or

Cesarean room because they are on the verge of delivering.

Adjacency Diagram

Birth Service Entry(Street Level

24 Hours )

Established OB Patient

OB Triage Unit(reception and

perinatal evaluation)

Cesarean / Obstetric Operating Rooms

Clinical Support and Ancillary

Services

Pre-operative Prep(scheduled pts)

Extended Care Unit

(ECU)

Mother/Baby Recovery

(PACU)

Postpartum Room

Antepartum RoomHome



lockers)

Obstetric Observation LDR Unit

Clinical Support and Ancillary

Services

OB Patient Flow from L & D to:

“Labor and Delivery” Internal Functional Adjacencies and Flow

“Labor and Delivery Unit”

Sec3:67

Key Functional Adjacency Requirements include:

Labor and delivery should be easily accessible to the NNICU, materials management, families, GYN operating rooms, ICC •

and emergency department among other requirements.

GYN ORs and pre/post operative care will be on the same fl oor as L&D for convenient access and safety.•

- Obstetric triage should be accessible without walking through other patient care areas.

- Many patients will be transported from this fl oor to an inpatient unit for postpartum and antepartum care.

Designated elevators are planned for staff, patients including NNICU babies, visitors and supplies to decrease travel

time, improve effi ciency and patient safety.

- Path from entry into the hospital building to this fl oor should be convenient and easy to access with short term parking

for women in active labor.

FUTURE FLEXIBILITY

Expectations for projected growth was described by PHHS as gradual, resulting in the consideration of shelling eight •

observation rooms that would be considered soft space for future growth. The original 48 LDRs were consolidated with the 5

ECU rooms assuming fl exibility.

Several benchmarks and comments about utilization were requested by and provided to PHHS, although recommendations •

about the quantity of rooms were not part of this project. The following information was provided regarding fl exibility and

benchmarks.

Other large volume birth services analyzed the implications of changes in Cesarean rates, induction rates, academic •

requirements and many other factors as they embarked on new facilities. A common objective was to achieve better

utilization of Cesarean operating rooms, one of the higher cost rooms to newly construct and operate in the hospital. For

example, three large birth volume hospitals streamlined their Cesarean operating room utilization as follows:

- Prentice Women’s Hospital, affi liated with Northwestern University’s academic teaching program and located in inner

city Chicago has 4 Cesarean ORs for 13,600 annual births and a 30% Cesarean rate. Elective OB and GYN surgeries

do not occur in these 4 rooms routinely, other than elective Cesareans. Management indicated that they would like to

have had a 5th OR for growth, but are managing the volume for now.

- Northside Women’s Center at Northside Hospital in Atlanta has 5 Cesarean ORs with 18,000 annual deliveries and a

39% Cesarean rate last year. Many of the Cesareans are scheduled and they moved to a more staggered and effi cient

scheduling process to accommodate the high volume.

- Women’s Hospital of Baton Rouge in Louisiana implemented a patient itinerary where patients are given a checklist

and asked to help monitor the activities needed to occur from admission to discharge (e.g., baby photo at 11 am).

Positive results include better room turnover, increased patient satisfaction, reduced length of stay, and decreased

workload for the nursing staff. They implemented this improvement in advance of planning 6 Cesarean ORs, 13 pre/

post-op rooms and 28-32 LDRS for their new campus. They had approximately 8,500 births in 2007, but projected

growth is unknown. The project is on hold pending fi nancing at the time this report was written.


Sec3:68


Neonatal Intensive Care Unit - 120 Beds•

Neonatal Intensive Care Unit Core + Administration•

Neonatal Intensive Care Unit Satellite Pharmacy •


Proven evidence-based design related to the benefi ts of controlling the •

neonate’s environment from sound to lighting and stimulation.

Identifi ed best practices for implementation of an expanded, universal single •

family room model and family centered newborn intensive care; appropriately

sizes of patient rooms, ancillary space and staff support space such as on-call

room ratios and staff lockers; standardized support spaces when appropriate

and streamlined operations.


status.


general consensus.




Parkland’s Neonatal Intensive Care Unit (NNICU) provides a full spectrum of •

care to the most critically ill and premature newborns. Parkland often refers to

this unit as the NNICU, which is used interchangeably with “NICU” in this report.

Established in 1968, the NNICU was the fi rst and largest neonatal intensive care •

unit in north Texas. The scope of services includes:

Comprehensive, multi-disciplinary medical and surgical services from birth to •

discharge.

Infant resuscitation and stabilization for the Parkland delivery service.•

Guidance and follow-up for parents of neonates.•

Education of nurses, medical students, residents and fellows. •

Excludes major cardiac surgery, specialized imaging and ECMO (extra corporeal •

membrane oxygenation) that are provided at nearby Children’s Medical Center.


Limited fl exibility: multiple levels of services and locations exist and are divided •

by medical acuity and provider coverage, ranging from the lower acuity

continuing care to acute and intensive care (Level III) in almost 100 beds

currently. Services are physically separated. Continuing care patients are

accommodated in a distinct unit separate from acute and intensive care.

Step-down nursery is where babies and their families prepare for discharge.

Six beds are designed for developmental needs: a gift from the Crystal Charities •

Ball enabled the provision of a 6-bed area in the NNICU concentrating on the

developmental care of infants in 2001.

Functional Narrative - Neonatal Intensive Care Unit

Sec3:69

Neonatal mortality is on par or better than national norms: mortality rates are better than average, according to a report in •

the agenda for the Quality and Risk Management Committee of the Board of Managers at PHHS on August 26, 2008, although

some of the sickest babies are transported to Children’s .1

- National mortality rate is 6.78 per 1,000 and PHHS rate is 3.4 per 1,000 (National Perinatal Information Center - NPIC).

Multi-disciplinary staff: staff include RNs, pediatric and neonatal nurse practitioners, neonatology faculty from the •

University of Texas Southwestern and many multidisciplinary employees ranging from respiratory therapists to nutritionists.

Compact, crowded facilities and limited ability to control the environment: current facilities average far less than today’s •

minimum standard of 120 clear square feet per baby excluding aisles. Efforts are being made to manage light, stimulation,

air fl ow and noise, but the small, open rooms are not conducive to controlling the physical environment or fully support

individualized, developmental care objectives. Efforts consist of “quiet time” with dimmed lights and softer voices in the

more crowded rooms and a few additional environmental controls are offered in the 6 bed developmental care room.

Family-centered care is not supported by facilities: infant care spaces are not conducive to keeping parent and infant •

together when appropriate. The tight quarters do not allow parents the option of more privacy and confi dentiality from other

families when desired. Parents may be asked to leave their infants’ bedsides during rounds or if something is happening

with the neighboring babies that would make it uncomfortable or inappropriate to observe. Privacy panels are used when

feasible for skin-to-skin contact and other times when privacy is ideal, but the small size of spaces and the inability to reduce

sound and full visual blocking make this challenging.

Small entry: a bank of institutional scrub sinks creates a stark entry to the unit. Continuing into the unit, this view is •

softened by photos that feature graduates and a small desk to the side that is staffed for the reception and control functions.

Limited staff support space: While the emerging trend is to provide options for parents to share in nurse reports and •

physician rounds related to their individual babies, there are no private bedside spaces for this practice currently. Staff do

not have a place for shift report if they would like to communicate with each other off-line. Locker, lounge and work spaces

are undersized and appear to be squeezed into areas not intended for these functions.

Ancillary, technology and other challenges: Pyxis fi lls are done 2-3 times daily from MRD and in-unit storage is limited. •

Pediatric radiology services such as MRIs and even the capability to perform ECHOs at the bedside on any patient result in

some patients being transported to Children’s. Complex surgical cases for babies who are too unstable to move present

challenges.

1 Source: www.parklandhospital.com/media/pdf/BOM_082608.pdf with references to Drs. Alexander and Bloom and Miriam Sibley.


Sec3:70


Model of Care:

The future design will support a model of care for the 120 bed NNICU requested by PHHS with these six primary •

considerations:

- Suffi cient space for patient, staff, family, teaching and research functions.

- Avoid noxious noise, light and stimuli from adjacent beds that impede care and development.

- Support the right to privacy and confi dentiality.

- Enhance safety (e.g., through design supporting reduced risk of infection).

- Support family accommodations, communication and involvement in care.

- Provide sustainable and effi cient facilities.

NNICU program includes all levels of newborn inpatient care except for newborn nursery care. •

NNICU user group recommended that the program include suffi cient space to accommodate an all single family room (SFR) •

design, while continuing to work toward consensus about the model of care and operational plan. PHHS Steering Committee

supported the SFR recommendation.

SFR design is fast becoming the prevailing design model to support evolving models of care for new construction of NICUs. •

More than 40 NICUs have converted to this design during new construction or major renovation in the US since the 1990s and

many more are in the planning stages. (TAC requires a minimum of one single family room for every six beds).

First recorded SFR was built in Brest, France, and was implemented to improve infection control in 1985, which was achieved •

successfully. Other units have evolved to this design because it strongly supports the premise of providing individualized

environments for the neurological and other sensory development of premature infants. Others base their rationale on many

of the same reasons that adult rooms are being converted to private rooms – for confi dentiality, privacy and control. Family-

centered care has been one of the key drivers, also.

Space Program:

Patient Rooms

Individual, standardized universal rooms programmed for all levels of acuity within a consolidated NNICU, including ICN, •

ACN, CCN and the “K Nursery” (maximum fl exibility).

Flexibility to cluster patients within the design by acuity or for other reasons, but without restriction because of room size.•

Space within each room for patient(s), equipment, supplies, staff work area with handwashing sink, family with daybed or •

sleeper, chair for skin to skin care, family personal storage, acoustical considerations, controlled lighting and individual

thermostat, among other features.

Patient Unit Layout

Single fl oor recommended with ten groupings of twelve rooms.•

Controlled reception and entries that support security. •

Perimeter windows and access to natural light would be provided based on data that supports benefi ts of natural lighting for •

adults (staff and families). Natural lighting as specifi cally benefi cial to premature babies would not be the driver for this

feature, since premature babies do not have the neurological maturity of a term baby.


Sec3:71

Consistent model of care. Combination of multiple design models such as 50% pinwheel and 50% single family room is not •

recommended. Leadership from the Children’s Hospital of Denver built 30 single family room and 30 open pinwheel beds.

The NNICU director and staff reported at a national conference on Jan 22, 2009, that the mix of rooms was a signifi cant

family and staff dissatisfi er, based on their surveys. A poll showed that an overwhelming majority of staff would go with all

SFR in hindsight. Similar fi ndings have been experienced at several other hospitals with mixed models such as Providence in

Anchorage and Phoenix Children’s during a past interim construction project.

Procedure Room

Accommodates surgical light and other appropriate equipment for procedures.•

Cleanable surfaces and appropriate ventilation.•

Neonatologists are increasingly providing bedside procedures and procedures outside of traditional operating rooms. •

Observation of trends and a literature search on neonatal bedside procedures substantiate the practice. Examples of studies

that support bringing the surgeon to the bedside for certain procedures include:

- Article by Arbell et al in IMAH, Vol 9, December 2007, titled “Bedside Laparotomy in the Extremely Low Birth Weight

Baby: A Plea to Bring the Surgeon to the Baby”.

- Article by John et al titled “Improving the management and delivery of bedside patent ductus arteriosus ligation” in the

August 2007, AORN Journal:

“ ...if surgical intervention is the required method of treatment, often the procedure needs to be performed in the NICU

at the patient’s bedside. Keeping the patient in the NICU can be safer than bringing him or her to the OR. Patients with

PDA are most often critically ill, premature infants who are intubated and on mechanical ventilation. According to

Gould et al, (2) transfer of these premature patients has been associated with hemodynamic instability, inability to

maintain optimal ventilation and oxygenation, hypothermia, dislodging of the endotracheal tube, and loss of indwelling

lines causing interruption of continuous infusions. In addition to not moving a patient with a critical airway to the OR,

performing a PDA ligation in the NICU has advantages ...”

Satellite Pharmacy

Distinctive satellite NNICU pharmacy in or adjacent to the NNICU - based on best practices.•

High volume user of medications that are specialized for infants and detrimental if confused with adult dosages, as evidenced •

by recent and widely publicized cases of neonatal medication mix-ups at Christus Spohn Hospital in Corpus Christi, Texas,

Cedars Sinai in Los Angeles and Methodist in Indianapolis.

Proposed pharmacy includes:•

- Order processing and pick-up with a walk-up window serving clinicians fi lling patient orders

- Storage and staging space

- Compounding and packaging

- Specialty cart and tray staging/storage

Lactation Areas:

Centralized “formula” room as required by TAC and needed in the unit.•

Three additional lactation rooms that could be used to support breastfeeding supplies, pump storage and other needs. •

Expect most breastpumping in single family rooms but allow option based on experience at other hospitals where some

women are more comfortable in separate room without NNICU staff in this space caring for the infant. At other NICUs, the

culture is to use breastpumping as a means for mothers’ socialization and the space is shared with curtains.

Refrigerator/freezers for breastmilk provided in each of ten clusters of rooms. PHHS did not want individual refrigerators in •

patient rooms for breastmilk. This feature is common in new single family room NICUs to minimize breastmilk mix-ups.

When utilized, requirements include quiet refrigerators without freezer shelves, protocols for cleaning and electronic

temperature regulation/alarms.


Sec3:72

Simulation Lab

Practice lab for staff required as part of the unit for “on the job” teaching for all nursery levels of care. •

PHHS determined that is needs to include future capacity for two simulation babies.•

Staff Support Space

While decentralized work stations are requested near the patients to reduce walking distances and improve effi ciency, four •

hubs (communication centers) with one designed as a central command center for 4-5 people simultaneously will support

staffi ng needs. PHHS expressed strong support for “hubs” rather than total decentralization of work stations resulting in a

hybrid model.



Utilization/Volume

PHHS leadership analyzed several potential scenarios related to NNICU bed need, resulting in the conclusion that 120 beds •

would be the appropriate projection.

Since previous documents had different conclusions about bed needs, the next few key points are summarized to help trace •

and document the steps.

When reviewing the strategic planning volumes that are shown in the following table, the projected need was 96 beds, but •

appeared to exclude the “K” or “Sick Nursery”, level II beds.

PHHS approved budget for the NNICU (2008) was associated with the square feet in an HKS space program for 77 Level III •

beds, and appeared to inadvertently exclude the program numbers for intermediate and sick nursery needs. These 77 beds

were part of 128 total beds programmed initially for a separate women and infants’ hospital (2004).

Women and Infants leadership reviewed these documents, recent trends and projections and provided a revised projection of •

120 beds.


Total Change 06-12


FY17

Nurseries

ICN Patient Days 6,191 5,898 6,399 5,736 -1.5% 1.9% 5,845 1.0% 5,903

Average Daily Census 17.0 16.2 17.5 15.7 -1.5% 16.0 16.2

ACN Patient Days 9,794 11,313 11,184 10,975 2.4% 1.9% 11,184 1.0% 11,295

Average Daily Census 26.8 31.0 30.6 30.1 2.4% 30.6 30.9

CCN Patient Days 5,282 5,300 6,151 6,810 5.8% 1.9% 6,939 1.0% 7,009

Average Daily Census 14.5 14.5 16.9 18.7 5.8% 19.0 19,2




Sec3:73

Staffi ng:

Current nurse to patient staffi ng ratios range from 1:1 to 1:4, generally. •

Research from existing facilities has shown that nurse staffi ng ratios and nurse caseloads remained unchanged in the •

single family room model in comparison to open bay models. (Sources: Boekelheide NICU at Sanford Children’s Hospital –

staffi ng analysis was part of a 3 year investigation of differences in NICU environments; Children’s Hospital, St. Paul, MN,

and St. Luke’s Hospital, Cedar Rapids, IA). Some hospitals reported an increase in technical support, unit secretaries and

aids due to spreading out in more space than previous units.


The following diagram depicts the internal functional relationships and fl ow. Examples of clinical support and ancillary services

included in the green oval are the satellite pharmacy, MRI and other imaging services and a variety of therapies and many staff

support areas from work stations to child life storage, nutrition and social work.

Adjacency Diagram

Neonatal Intensive Care Unit Internal Functional Adjacencies and Flow

In-born (Labor and Delivery, ICU

or Trauma)


Services

Transport/Transfer: ED, Ambulance, Air

Newborn Nursery

Children’s or other hospital

Neonatal Intensive Care Unit

Home, Morgue, Transport


lockers)

Satellite Pharmacy

Key Functional Adjacency Requirements include:

NNICU and labor and delivery must be readily accessible.•

Patients will be transported to this fl oor resulting in designated elevators for staff, patients, families, visitors and supplies to •

decrease travel time, improve effi ciency and safety. These elevators should be controllable for patient transport.

Clear path from emergency transport and receiving area.•

The NNICU should be designed to avoid cross traffi c from other units.•

Strategically positioned stairwells for staff and others who prefer stairs.•

Convenient access to materials management, garage storage, labs and ancillaries.•


Sec3:74

FUTURE FLEXIBILITY

Universal rooms will allow better accommodation of fl uctuating acuities and census than if spaces were designed only for •

specifi c levels of care.

Other opportunities for increased fl exibility and growth in census are achieved in some NNICU by providing suffi cient gases, •

outlets and space to co-bed siblings in the same room, keeping low level II babies with moms on the postpartum unit (e.g.,

moderate feeding issues, antibiotics, phototherapy) and reducing average length of stay due to the ability to better prepare

parents for discharge in an environment that encourages “rehearsals” in the private patient room before taking the baby

home.

Some hospitals add space for “phantom” beds in each room for rare surges, resulting in a design with headwalls for two •

patients in a single patient room.

During the design phase, PHHS is expected to consider evaluating these and other options for fl exibility.•

Because this proposed change in the model of care and design is expected to require one of the most signifi cant transitions •

in the new facility, this document includes additional details that are beyond the usual supporting documentation in this

report. The following material was discussed in the user group meetings related to best practices, future needs and

outstanding issues.

NICU Examples:

A few examples of teaching hospitals that have or are implementing the single family room model include:

Vanderbilt Monroe Carell, Jr., Children’s Hospital at Vanderbilt, 60 beds (2004)•

Sioux Valley Hospital USD Medical Center; Sanford Children’s Hospital, 58 beds – 46 single plus triplet and twin rooms at •

Boekelheide NICU (2006)

Nebraska Medical Center, Omaha , 34 beds (2005)•

Children’s Hospitals and Clinics of St. Paul, started with 50 bed with expansion being planned (2003)•

Virginia Commonwealth University Medical Center, Richmond, VA , 40 beds( 2008)•

University Hospital’s Rainbow Babies and Children’s Hospital, Cleveland, affi liated with Case Western Reserve University •

(had a portion of SFR since 1999 and evolving to all single room – under construction , 82 beds (1999/2010)

St. Louis Children’s Hospital, Missouri (75 beds being phase in over time)•

Rhode Island Women and Infants / Brown University – 80 beds (2010)•

Johns Hopkins Medical Center, Baltimore, 46 beds (under construction)•

Recent construction with other design models includes:•

Morgan Stanley Children’s Hospital, New York, NY, 50+ semi-private patient pods with family support at bedside (2003)•

Prentice Women’s Hospital , Chicago, IL - 86 bays with sliding doors for extra space; sized at approximately 120 nsf; do not •

allow parents to stay at the bedside overnight; two mother/baby suites with double beds for parents and one or two

additional overnight parent rooms (2008)

Winnie Palmer Hospital for Women and Babies, Orlando, FL - semi-private rooms, 112 beds (2006)•

University of Iowa Hospitals and Clinics, replaced 46 bed NICU with combination of single and multi-bed rooms (2004)•


Sec3:75

CHER Study1

A 2005 study of 11 NICUs by researchers from Texas A&M , USF and Memorial South Bend, included the following fi ndings:

“Based on the results of this preliminary study, single family room NICU design provides solutions for increasing parent privacy and

presence, supporting HIPAA compliance, minimizing the number of undesirable beds, increasing staff and parent satisfaction, and

reducing nursing staff stress. Potential limitations of the SFR design are reduced parent-to-parent social contact and isolation of both

parents and staff. In the projects reviewed in this study, construction cost was not infl uenced by design confi guration; therefore, the

decision to provide SFR units should not be infl uenced by fi nancial implications. The primary motivation for employing SFR design should

be the provision of an environment that supports quality care for infants and that offers a supportive experience for parents and nursing

staff.”

Several outstanding issues identifi ed by the user groups as requiring future resolution are documented in this report and include:

Resolve Children’s Medical Center and PHHS proximity issues: develop plan to address the implications of the increased 1.

distance required for transport of babies between Children’s and Parkland; continues to be a serious concern at the time of

this documentation. A separate study of this topic for hospitals from across the country was conducted and provided to

PHHS as an additional report for this project.

Confi rm a common vision: a common vision is a good anchor for design. Physician and PHHS leadership were working 2.

toward confi rming a common vision on some priorities for the project including translating care priorities into a preferred

design model

1 Harris, White, Shepley et al, NICU Environmental Design Research: The Impact of Single Family Rooms on Patients, Families, and Health-

care Staff, CHER, Nov 2005.


Sec3:76


Intermediate Care Center (ICC)•


Proven evidence-based design related to size and confi guration of •

patient exam rooms and functional adjacencies for similar services.

Identifi ed best practices for urgent/immediate care •

centers for obstetrics and gynecology.

Completed staff questionnaires.•

Series of PHHS user group discussions resulting in •

recommendations and general consensus.

PWC- PHHS strategic planning documents that provided the quantity of exam •

and other patient rooms and supporting projections for patient care space.


Mostly urgent to emergent care for obstetric and gynecological problems, •

but not a trauma unit (e.g., vaginal bleeding, pelvic pain, problems

associated with gyn/oncology, obstetric patients usually up to 24 weeks

gestational age). Some non-urgent outpatients are seen in the ICC.

Alleged criminal assault patient services.•

Prisoner obstetric/gynecology services.•

ICC is not equivalent to other hospitals’ use of “Obstetric Intermediate Care •

Unit” that denotes an inpatient or observation unit for high risk patients,

usually in regional perinatal centers. This other use of the term refers to

the care of the highest risk obstetric inpatients by obstetricians to result

in fewer transfers to medical/surgical intensive care units. PHHS uses

the ECU for this level of care and the antepartum/postpartum units, once

the patient is more stable. ICC is similar to what a few hospitals refer

to as an “Immediate Care Center” for obstetrics and gynecology.


Generally “walk-in” patients although some women may arrive by •

ambulance and be screened by the emergency department.

Care begins with triage upon entering the ICC; from triage, •

patients are directed to the appropriate treatment.

Some patients are sent to the emergency department, labor and delivery, •

GYN surgery or other locations when they arrive at the Intermediate

Care Center (ICC) with problems that should be treated elsewhere.

Large, usually crowded waiting area without separation •

of obstetric and gynecological patients.

OB patients are seen fi rst, unless it is a GYN emergency. •

Patients seen quicker because is a dissatisfi er when patients

with long dwell times see others “jump” ahead of them.

Functional Narrative - Intermediate Care Center (ICC)

Sec3:77

Additional defi ciencies in current spare are described as “not enough exam rooms and counseling areas, observation beds •

without privacy; limited work area for staff starting IV’s and drawing blood; lack of space for visitors; limited lab space and

lack of confi dentiality in registration areas”.

Sonography services are provided in the ICC.•

One negative air pressure provided for isolation currently.•


Model of Care:

Model of care is based on the provision of midlevel providers who screen patients to determine the emergent needs and then •

direct them to receive the appropriate test, treatment, counsel or observation either by the ICC providers or referral to other

providers.

Future model is that the ICC will continue to treat the patients with non life-threatening obstetrics and gynecology conditions. •

The ICC will serve the community needs 24 hours and contribute to PHHS’ safety net service, with no appointment required.

Space Program:

Entry / Reception

ICC should have an entry that is ground level and in proximity to emergency departments. •

Large number of “tags”, also referred to as entourages and chaperones, accompany patients creating need for ample waiting •

space.

Triage and Registration

PHHS prefers separate paths for gynecology and obstetric patients with separate waiting; as processes become more •

streamlined and ideally most patients go directly into rooms for exam and treatment, the waiting area would be less of an

issue; future considerations for streamlining ICC fl ow include:

- Use of new technology to improve patient experience and effi ciency.

- Non-urgent care diversions; reduce unnecessary bottlenecks.

Patient Care and Other Key Rooms

Proposed rooms include: 4 triage, 12 exam/treatment, 6 observation + 2 special rooms, totaling 24 rooms for patient care.•

Four registration/interview areas will be provided as a front end function of the center.•

Resuscitation room is needed for safety in the event patients cannot make it to other locations for unexpected emergencies.•

Alleged criminal assault area should be in secure, discrete part of the center with access to a toilet, clothing closet and •

subwaiting for an offi cer or support person.

Ancillary Services

Suffi cient space for lab (two point of care testing stations), pneumatic tubes, medication, sonography and other ancillary •

space is programmed with the intent to improve the current defi ciencies identifi ed regarding ancillary and clinical team

space.


Sec3:78

General Layout

Decided not to combine obstetric triage (Labor and Delivery) and obstetric ICC, based on volume, processes and the reality •

that all of the obstetric services and ICC are unlikely to fi t on one fl oor, and remain in proximity to the emergency

department.

Determined that the path into the ICC should be designed to avoid congestion of ambulatory and other ICC patients with other •

high volume areas and to provide appropriate security for this 24 hour operation.



Peak operating hours are 1:00 pm to 12:00 am•

Utilization / Volumes:

ICC is predicted to continue to grow and serve as a women’s urgent care center. Projected volume provided for this project is •

shown in the following table:

Staffi ng:

Current staffi ng includes 11 to 14 full-time equivalents (FTEs) with the highest number during the day shift. •

Key staff include: 3 managers, 1 RN charge nurse, 1 RN triage, 1 RN fl oat, 1 RN observation, 1 med director, 2 physicians •

and 3 midlevel practitioners.



Total Change 06-12


FY17

ICC 21,293 20,837 19,319 20,792 -.5% 4.9% 21,811 9.7% 23,926



Sec3:79


Adjacency Diagram

Direct / Hospital Entry

ACC/Clinics/Family Planning/Jail

Emergency Department

Admin and Staff Support (eg,,offices, lounges, conference, lockers)


Services

Intermediate Care Center

Intermediate Care Center (ICC) Internal Functional Adjacencies and Flow

Sonography/Imaging

ICC Triage

OB GYN

Home, Jail, L&D, Postpartum, Antepartum, GYN, OR, ED, Med/surg,

Morgue, Clinic


Key Adjacencies include:

Emergency department – some cross fl ow of patients expected.•

Access to imaging/radiology.•

Close to OB Complications Clinic/Genetics/Sonography/GYN Clinics.•

Elevator access to Labor and Delivery triage, assuming on another fl oor.•

- Pregnant women greater than 22-24 weeks gestational age with complaints of decreased fetal movement may be at

risk for fetal demise. For this reason, if these women arrive at the ICC instead of the L&D unit, the design and process

should support swift transport to L&D without waiting time in the ICC. Long distances to L&D or “Keeping a pregnant

woman sitting in a waiting area or waiting to be evaluated for a long period of time is a prescription for liability”. 1

FUTURE FLEXIBILITY:

Triage, observation and exam/treatment rooms are sized uniformly for fl exible use should needs change regarding the •

allocation of each of these types of spaces.

Discussion and planning about how the emergency department triage and the ICC triage will interface optimally is expected •

to continue and could impact future operations. Initial discussions identifi ed relationships between the ICC and ED regarding

security and ICC patients’ entry to the building, but not shared exam and treatment rooms since each service had high

volume.

Recent and future emergency department protocol changes could have relevancy for the ICC, too.•

1 Mahlmeister L, Van Mullem C. The process of triage in perinatal settings: Clinical and legal issues. J Perinat Neonatal Nurs 2000;13:13–

30.

Sec3:80


Emergency Services•

Shared ED Admin•

Psych ED•








The emergency room at Parkland hospital is one of the busiest in the country.•

In 2006 there were 87,315 visits to the Main ED.•

This volume is expected to grow to over 100,000 by 2017• 1

Parkland is designated as a Level I Trauma center. •

Parkland is a regional designated Burn Center accredited through the American •

Burn Association and serve both pediatric and adult patient populations.

Over the last 6 months PHHS has received Stroke Program accreditation by the •

Joint Commission.

The Parkland’s ED currently serves as a major hub and treatment center for •

routine acute care for the indigent and Medicaid population in Dallas County.

Command Central Bio-Tel for both EMS-ground and air transport is located •

within the ED suite.

The Emergency Department at Parkland Hospital is crucial to both the emergent •

care of patients and as a point of access/entry to the hospital.

Currently 80% of all PHHS admissions come through the Emergency •

Department.

According to Price Waterhouse Cooper research and data, 60% of the patients •

who come to the ED are repeat patients.2

Approximately 10 - 11% of the emergency room visits result in admissions.• 3

The psych emergency room and the ICC are adjacent spaces and provide •

specialized care to specifi c patient populations.

1 Source: Kaufman Hall 2006 data (9months annualized), Price Waterhouse Coopers

(PWC) Volume Capacity, Projections. Master Facility Plan, June 2007.





Functional Narrative - Emergency

Sec3:81


While the Emergency Department works aggressively to manage patient fl ow, sources of ineffi ciency include a poorly •

functioning front end: triage and registration and ineffi cient means to manage the large volume of patients who require urgent

care.

The ED waiting space is out of the line of site of the ED. This creates a situation where it is possible to be in the back of the ED •

and have no idea how many patients are waiting.

The current space confi guration of the ED which separates patients into medical and surgical tracks in different geographic •

spaces leads to ineffi ciencies in staffi ng, management oversight, supplies, and transportation of patients.

Patients who require chronic dialysis and non-emergent orthopedic referrals from outside EDs, are two specifi c large volume •

populations who need to be effi ciently managed and processed.

The current average wait time in the ED is about 10 hours.•

The current confi guration of the decontamination support is not optimal. The current fl ow of patients, staff, and vehicles •

during a time of decontamination is chaotic as a direct result of the current space, equipment location, driveway, etc.

confi guration.

Although adjacent the Psych ED and the ICC have no direct connections to the Main ED. When emergencies occur in theses •

spaces or a patient needs a service offered only in the Main ED delays result.

Vertical and horizontal pathways to the OR, cath lab, and GI suite are not effi cient.•

Vertical and horizontal access to the heliport are not effi cient.•


Model of Care:

Incremental growth has been projected for the Emergency Department• 1, however PHHS new strategic endeavors: CT surgical

program, Stroke Program Certifi cation and plans to become part of NCI Cancer Center may bring an increased volume to the

ED that was not considered at the time of Price Waterhouse Cooper’s assessment.

Parkland Hospital will continue to be a Level One Trauma Center•

Parkland Hospital will continue to be a Burn Center treating children and adults.•

PHHS will treat a growing number of patients who require emergent neurosurgical intervention as a result of their Stroke •

Program Certifi cation.

The cardiology and CT surgical volumes may continue to grow as a result of reestablishing a CT surgical program at PHHS •

and the newly accredited interventional cardiology fellowship program. In addition the number of patients seeking routine or

urgent care through the emergency department may continue and as PWC projected continue to grow.

The ED leadership is currently reconfi guring and their operating model of care delivery. Lean operations will be implemented •

in the future space.

The following assumptions: Guiding Principles were used when developing the ED program.•

- Patients with acuity Levels 1-3 will be treated / evaluated in the ED

- There will be an Urgent Care / Fast track in the future ED

- There will be no clinical observation unit managed by the ED

- Care will be delivered by teams and space will be designed in complementary modules to support this operating model.

- Quick Triage will take between 5-8 minutes.

- Goal - Door to MD time in the future will be 24 minutes. This time was based on like benchmark hospitals ie. Detroit

Receiving Hospital.

- Goal - Patients who are being admitted will have a bed within 6 hours, patients who are discharged home will be

discharged within 4 hours.

1 Source: Kaufman Hall 2006 data (9months annualized), Price Waterhouse Coopers(PWC) Volume Capacity, Projections. Master Facility Plan,

June 2007.


Sec3:82

- Goal - Patients who are treated in the urgent care / fast track will be discharged home within 4 hours.

- PHHS will develop a primary care strategy to treat patients who currently misuse the ED in the community.

- ICC and Psych ED will be located adjacent to the main ED with off stage connectivity so if emergencies arise and a

patient needs to be transferred or responded to in any area there is close proximity.

- Registration will occur in a decentralized way at the patient bedside.

Disaster Preparedness: Parkland hospital is a designated disaster site. Staff has requested that this space be designed to •

function like an “Emergency One” model. PHHS staff has also requested that the space reference and support the

operations similar to Magen David Adom Hospital in Israel . These requests and details should be further discussed during

the next phase of this project.

Space Program:

Ambulance:• The future ED space should be designed to with separate ambulance and walk in entrances. The ambulance

access should be large enough to accommodate the ambulance volume as well as the transport of inmates and psych

patients who are escorted to the ED.

Heliport: • Effi cient access to the heliport is imperative. Heliport access to the ICU and OR should be part of the future

design.

Security spaces: • All patients, visitors entering the ED will go through metal detectors.

-Security / Control Station: This space is programmed to be 100NSF.

-Police workroom: This space is programmed at 252 NSF and will accommodate 4 computer workstations.

-Gun Lock-Up Room: This should be a secure space with internal secure gun lockers.

Waiting space: • To accommodate 200 people is planned.

Front End: • In the future it is assumed that patients will come to the ED and sign in. Within a brief period of time they will be

called to a quick triage point, where an experienced professional (physician - nonresident, midlevel provider or experienced

nurse) will triage patient based on chief complaint, basic demographics, vital signs, quick assessment. Patients will be given

an acuity score and sent to the most appropriate treatment space. Registration will be decentralized and occur at the

bedside.

Centralized command space• is planned and should be equipped with an electronic tracking board to assist with

management and coordination of patient fl ow.


Sec3:83

Admissions / Bed Flow:• Currently there is considerable backup of patients waiting for beds. This is part of a larger problem

resulting from a multitude of issues related to discharge, room turn-over time, etc. A clinical decision / observation unit and

a discharge lounge are planned for the new hospital. Both of these spaces should help to create effi ciencies with bed

management and patient fl ow. Implementation of these measures should decrease / resolve the delays currently

experienced by patients admitted through the ED.

Disaster Preparedness:• Parkland hospital is a designated disaster responder. Decontamination space has been

programmed. Staff have requested that this space be designed to function like an “Emergency One” model. This program

and detailed operations should be discussed further during the design phase of the planning.

Treatment Spaces:•

- There will be 112 treatment spaces confi gured into self-contained modules of 14 rooms. All treatment spaces will be

universal and equipped to manage critical care patients. Decentralized / bedside computers for orders and charting

are requested.

- Six (6) Resuscitation Rooms are planned. These spaces should be adjacent to the CT scanners. These rooms should

be equipped with general imaging equipment that can fl ex between the rooms via a ceiling track. These spaces

require close proximity to the ambulance entry and immediate proximity to elevators providing transportation of

patients to the OR’s, ICU’s, Cath. or GI suites. A horizontal adjacency to radiology (IR, MRI, etc.) is planned.

- Specialized spaces: Ophthalmology, Dental, Orthopedics-which includes imaging capabilities and casting space.

Imaging: 2 general radiology modalities to support main ED in addition to modalities in resus space. 2 CT - to be •

located in close proximity to resus rooms.

Clinical Support:•

- Stat lab to support the ED is planned.

-Satellite pharmacy to support the ED is planned.

Provider Workroom: • 8 of these spaces are planned- one per module. They should be equipped with PAC viewing, computer

workstations.

Resident and Fellow • (offi ce) LRC’s are planned in close proximity to the ED.

Command Central / Bio-Tel• : to support ground and air patient transports. EMS support space should be located in close

proximity to this space.


Sec3:84

Service 2017 Visits

Less 30% of Level 4-

7 to Urgent Care

Less AdmissionHold/CDU

Average key room Minutes/

Visit

Total Key Room

Minutes

Key room Visits

Available / Room

Key Rooms Required at

85% Capacity


75% Capacity

2012 Assumed Key

Rooms

Visits / Key Room

Current Key

Rooms

Difference:Assumed vs.

Current Rooms

Psychiatric ER

Total 11,920

Daytime Volume Beds at 85% Beds at 85%

50% of Visits 5,960 60010 Hr ALOS

3,575,972 352,000 12.0 13.5 12 497

Overnight Volume

50$ of Visits 5,960 84010 Hr ALOS

Plus 4 hr Post

Sedation Observation

5,006,361 352,000 16.7 19.0 16 372

TOTAL BEDS 11,920 28 426 7 21

Psychiatric ER Volumes/Utilization – Detailed Information


Service 2017 Visits

Less 30% of Level 4-

7 to Urgent Care

Less AdmissionHold/CDU

Average key room Minutes/

Visit

Total Key Room

Minutes

Key room Visits

Available / Room


85% Capacity


75% Capacity

2012 Assumed Key

Rooms

Visits / Key Room

Current Key

Rooms

Difference:Assumed vs.

Current Rooms

Urgent Care Centers

Visits 18,334 180 3,330,175 525,600 9.0 10.5 10 1,833

Urgent Care Centers Volumes/Utilization – Detailed Information



- Most admissions occur between 3pm -11pm

- Most discharges occur between 12pm-4pm

Jail Health:

There will be treatment spaces within the Inmate Treatment Center where inmates requiring urgent type care can be •

managed.

Those inmates requiring emergent care (Levels 1-3) will be managed with in the main ED space.•

Psych ED:

The Psych ED will be adjacent to the main ED. Psych patients requiring general emergency room services can be easily •

accommodated within the Psych or main ED space. There will be a convenient fl ow between the two spaces.

The Psych ED will be located on the outer parameter of the ED to provide easy access for patients who are escorted by •

police. The sallyport adjacent to the inmate unit should support this space. Patients should go through main ED security.


The ED requires an immediate vertical adjacency with the OR suite to accommodate trauma patients. It is envisioned that a •

off stage bank of elevators will connect the ED/trauma bay with the OR.

There will be a vertical adjacency with the interventional space (cardiac cath and the GI Suite) to accommodate those patients •

requiring emergent endoscopic or catheterization intervention.

Radiology will be adjacent to the emergency department. It is imperative that the ED physicians, trauma surgeons, etc. have •

easy access to the radiologists. Radiology reading space has been programmed in the new space

Adjacency Diagram


ED

ICC

Imaging

Clinical Lab

ORInmate Treatment

Center

Psych ED

IP Units

Interven-tional Unit

Sec3:85

Sec3:86


Psych ED•








The Psych ED provides 24/7 emergency services to adolescents over the age of •

13 and adults with psychiatric disorders.

Background / Current State

Patients arrive in department through either the “Back Door” (involuntary, with •

police) or via Triage (voluntary) from the main ER.

Back Door patients are registered and briefl y interview by a 4 person team to •

determine level of dangerousness.

Dangerous patients are medicated and placed in a secured seclusion room. •

All other patients are processed in, including vital signs and lab draw. •

Voluntary patients are fi rst interviewed by a nurse, then processed in by a tech •

and placed in the day room.

Dwell time lasts 10-12 hours. •

During this time the patient is interviewed by a provider, social worker, and drug •

& alcohol counselor.

After the evaluation is complete, the patient is either transferred to the inpatient •

unit or another hospital or referred to outpatient treatment.

Patients transferring to another hospital leave via the Back Door; patients going •

to inpatient unit or being discharged back to the community leave via the Front

Door.

Functional Narrative -Psych ED


Model of Care:

The Psych ED should be designed to provide maximum visibility for staff while at the same time there should be a feeling of •

privacy for patients.

The Psych ED would like to be able to provide a higher level of medical care in the new space: blood draw, simple procedures •

ie. stitches.

Space Program:

Waiting Spaces: • The Psych ED will have its own waiting space.

Treatment rooms: • There will be 18 treatment spaces confi gured into 10 exam rooms, 4 airborne isolation rooms and 4

seclusion rooms.

- These spaces should support capabilities to perform simple procedures, ie. sutures, etc.

Seclusion Room: • Private spaces where patients can be by themselves. Theses spaces should have remote video monitoring

for patient safety.

Provider workroom:• (2) 224 NSF workrooms are planned.

Staff support space;• lounges, lockers, etc. will be shared with main ED

Functional Narrative - Psych ED

Sec3:87


The Psych ED will be adjacent to the main ED. Psych patients requiring general emergency room services can be easily •

accommodated within the Psych or main ED space. There will be a convenient fl ow between the two spaces.

The Psych ED will be located on the outer parameter of the ED to provide easy access for patients who are escorted by police. •

Adjacency Diagram

Functional Narrative - Psych ED

Sec3:88

Lab Central

Imaging

Psych IP

Main ED Psych ED


Main Surgery (23 OR’s + 1 MRI)•







SCOPE OF SERVICES AND OPERATING PARAMETERS

PHHS only has a small fraction of the general and surgical subspecialty market •

in its’ primary service area- Dallas County. (2006-9 months annualized)

CT-5.1%, Urology- •

18%,Truama-22%,•

General Surgery-11%, •

Plastic-21%, •

Orthopedics-11%, •

Burns-82%. •

These numbers refl ect about 1/3 of the indigent population. •

Presently OR’s are dedicated to specialty areas:

General Surgery- 2 OR’s, •

Transplant- 1 OR, •

Plastic Surgery- 1 OR, •

Orthopedics- 3 OR’s, •

Urology-1 OR, •

Dental- 1 OR, •

GYN- 1 OR, •

Neurosurgery – 1 OR, •

ENT- 1 OR, •

Ophthalmology-2 OR’s, •

Vascular Surgery- 1 OR, •

Cystoscopy- 1 OR, •

Burn- 1 OR. •

Functional Narrative - Surgical Services

Sec3:89


Currently the surgical services at PHHS are performed in 18 operating rooms. •

Frequently elective or non-emergent cases are bumped because of trauma cases. •

In addition the current model of scheduling leads to ineffi ciencies and requires extensive work on the part of the OR director •

to maximize OR utilization.

The OR manager backfi lls cases daily-moment by moment to compensate for changes in the OR schedule and canceled •

cases in order to maximize OR time.

A strategic plan to secure future market and surgical growth is needed. •

Currently CT surgery only manages emergencies for patients who cannot be accommodated quickly enough at Zales or St. •

Pauls. Because of delays in much needed CT surgical procedures for the patients PHHS treats; there is a strategic initiative

to bring CT surgery to Parkland. A full CT service line is planned for the future.

The plans for PHHS to be a part of an NCI Designated Cancer Center in collaboration with UTSW, and recent Stroke Program •

certifi cation, and an expanded burn market should help increase surgical volumes as well as support the recruitment of

attending MD’s and trainee programs.

Parkland’s mission to serve the vulnerable- indigent populations in Dallas County has lead to a model of few privately •

insured patients. PHHS is embracing a strategic mission to increase payer mix.

Parkland continues to be committed to fellow, resident and medical student education and training. PHHS has the following •

accredited fellowships:

- Emergency Medicine,

- General Surgery-inc. Trauma, Urology, CT Surgery and Plastic Surgery.

As is the case with many institutions PHHS also anticipates a future shortage of anesthesiologists. •


Model of Care:

It is anticipated that PHHS will continue to realize growth in its surgical populations. •

There continues to be capacity at the Ambulatory Surgical Center, surgical volumes which are appropriate for the •

Ambulatory Surgical Center will continue to be routed to the Ambulatory Surgical Center.

Surgery services will include 6 distinct areas: Pre-operative services, Operating Rooms, Post-operative Services, Staff •

Support, General Support and Central Sterile Services.

The operating rooms are programmed to be confi gured around 2 cores. A case cart system will be implemented. Central •

Sterile will have direct vertical adjacency with the sterile core of surgery (1 clean and 1 soiled). There will be dedicated full

size elevators for easy and effi cient transport of equipment and supplies including case carts between the two locations.

Planning also includes dedicated elevators for the Trauma area in the Emergency Department and the operating rooms for •

the fast and safe transport of trauma patients. An elevator with direct access to the surgical ICU’s is also planned.

An interventional platform for invasive cardiac and GI procedures is planned. This suite will have a vertical adjacency to the •

operating rooms. This will provide economies with anesthesia.

Twenty-three (23) OR’s are planned.•

Four (4) OR’s will be dedicated to GYN services. •

All OR’s will be collocated on one fl oor. •

Labor and delivery will be located on the same fl oor as the OR’s. •

C-sections and elective obstetrical surgery will be performed on the labor fl oor, adjacent to the main OR’s. •

PACU/ recovery space and ECU will be contiguous for maximal fl exibility and anesthesia coverage. •


Sec3:90

Simulation Modeling:

Simulation modeling was performed and identifi ed that a total of 18 general OR’s was the sweet spot in terms of effi ciency •

(this excludes GYN volume).

Cases per OR were in the 850-900 range when simulated. •

At the far end of the spectrum simulation modeling demonstrated, that with effi cient smoothing of the schedule, PHHS has •

capacity for 1,042 cases per room with 86% utilization through 15 OR’s and 60% utilization through the 3 remaining trauma

OR’s.

Through discussion with OR and hospital leadership it was felt that a throughput of 1,000 cases per OR was unrealistic. •

Based on that determination, the decision to build 23 OR’s was made. •

Throughput time for academic medical centers ranges from a low of 600 (ineffi cient) to a high of 1,200 (extremely effi cient). •

It is anticipated that the average case time will continue to be 3.2 hours which is within the benchmark for teaching •

hospitals, (2.5-3.5 hours).

OR turn time is expected to be 20 minutes. Refer to simulation modeling in the appendix of this report. •

Space Program:

Public Spaces: • A 2,240 NSF space is planned to accommodate centralized surgical registration and waiting.

Operating Rooms:• 23 OR’s are planned. Two sizes of operating rooms have been programmed.

- Four (4) large operating rooms have been programmed at 720 NSF. These OR’s are sized to manage large orthopedic

cases, CT surgical cases with bypass, endovascular cases requiring imaging, and future use of robotics.

-Nineteen (19) smaller OR’s are planned at 680 NSF and will accommodate general surgical and other surgical

subspecialty cases. These smaller OR’s are sized to accommodate laparoscopic procedures.

OR’s are planned to be grouped into groups of 4 around 2 sterile cores.•

-Each OR will be equipped with several computers allowing for staff documentation and order entry.

-Imaging viewing stations will be accessible in each OR.

MRI:• An MRI suite fl anked by 2 of the large OR to be used for neurosurgical cases is planned. The MRI room should be

designed in such a way that it can be used for non-OR MRI cases when it is not in use for Neurosurgery cases.

Pre-op preparation area.• 24 single spaces are planned. The Pre-op area will utilize single patient spaces of adequate

size to accommodate a family member / support person. Anesthesia may utilize this space to insert invasive lines and

provide time consuming preparation activities rather than tie up an operating rooms.

Post-operative spaces:• 36 single spaces are planned to adequately support the operating rooms and are in compliance

with the Texas Administrative Code. Careful analysis has been given to these ratios based on an understanding of the

various types of procedures and expected room turnover rates as demonstrated in simulation modeling.

The • Post-operative areas will include PACU for stage I and stage II recovery. These spaces will be single patient spaces

with either 3 solid walls or 3 solid walls and a glass footwall. These spaces should be designed to provide optimal visibility

and patient safety while accommodating patient privacy.

Frozen section/Gross dissection:• will be located within the OR suite.


Sec3:91

Blood bank• will be located on the second fl oor of the hospital and have a vertical adjacency to the operating rooms. Other

laboratory needs and testing will be accommodated via pneumatic tubes.

A • satellite pharmacy will service the OR’s; specifi cally anesthesia needs. Medication dispensing machines will be located

in each OR.

The • Sterile Core will be supported by Central Sterile Services that will be vertically adjacent to the operating rooms with

full size elevators (1 clean and 1 soiled).

A three tiered system will be utilized for supply management. •

The case cart system will be managed by Central Sterile Services and provide necessary sterile instruments and supplies •

for each case. 2880 sf are planned for general storage and case cart holding.

Additional equipment storage in supply areas and in the OR’s to supplement as needed.•


Sec3:92

18 Pre-Op Holding Rooms

(Includes 4 Isolation Rooms)Need to adjust in inc burn and GYN

30 PACU(includes 8 Isolation Cubicles)

Need to adjust in inc burn and GYN

OR

OR

MRI

OR

OR

OR

Sterile Core

Blood Bank(W/I Surgery)

FrozenSection

AnesthesiaWorkroom

Surgery Patient

Check-In

Surgical Waiting

Surgery Public Zone

ConsultRooms

(Qty 2)

Pre-Surgical Testing

(30% day of surgery)

Operating Zone (assumes 18 + 1 burn and 4 GYN=23 OR’s)

Teaching/ Resident

TelMedRoom

ConferenceArea

SimulationLab

Education Zone

Staff Office Area

PhysicianWorkroom

CallRooms

Staff Lounge

Staff Lockers

Staff Support Zone

Morgue

Endo / GI / BroncDepartment

EmergencyDepartment

CentralSterile

SatellitePharmacy

(Located in ED, supports LDR and OR)

AnatomicalPathology

Surgical Connections

Surgery Services

Backstage connection for large specimens

Doesn’t require family to go to Morgue, while providing a backstage connection to the Morgue for body transport

Which education spaces will move across street needs to be determined with UTSW.

Positioning of GYN OR’s – requires additional input.

Needs further VP level discussion.

Backstage Transportation

Flash Sterilizing

OP & Same Day Entry

Pump Room

Control Room

Equipment Logistics

Not sure of location


The operating rooms in the inpatient hospital are open 24 hours a day 7 days a week.•

PHHS staffs 18 rooms Monday through Friday – 7 AM until 3 PM, 10 rooms from 3 PM -5 PM. Room utilization continues to •

decrease into the evening hours.


Sec3:93

KeyRoom 2006 2012 2017 KHC Request

Hospital Operating Room 18 20 22 23 OR

Prep / Hold Beds 6 10 11 14

PACU Beds 26 40 44 30 Main OR

Phase II / DSU Beds 39 30 33

ASC Operating Rooms * 0 6 6

Prep / Recovery Beds * 0 18 18

TOTAL OPERATING ROOMS 18 26 28 23

TOTAL PREP / RECOVERY BEDS 71 98 106 30

Existing Phase includes 2 East06/11 Includes 2 Procedure Rooms, 8 Prep / Recovery beds used for Endoscopy

Surgical Services Key Rooms


KeyRoom 2006 2012 2017 KHC Request

Hospital

Inpatient 2,181 2,801 2,926

Emergent 4,946 5,694 5,948

Same Day Admission 2,543 2,995 2,990

DSU (Outpatient) less ASC 5,393 3,615 6,546

ASC

Outpatient (Excluding Endoscopy) 6,000 6,000

TOTAL CASES 15,063 21,104 24,209

TOTAL ORs 18 26 28 23

CASES / ROOM / YEAR 837 812 872

Hospital Key Rooms




Surgical services should be easily accessible to the ED and ICUs to accommodate trauma and seriously ill patients, by a •

designated elevator.

Direct vertical adjacency to the Burn Unit is requested.•

Services such as Interventional radiology, imaging, blood bank and frozen section are accessed frequently and often under •

emergent circumstances, thus need to be in close proximity to the OR’s. Blood bank and frozen section spaces are

programmed within the OR suite.

The OR’s serve a large number of Day Surgery patients- thus easy way-fi nding from the front door is imperative.•

Waiting space for families / support person should be easily assessable to the ORs.•

Easy access to the cafeteria for staff on breaks – not consuming too much time should also be considered.•

Adjacency Diagram

PACU

Frozen Section

ICU

OR

ED

Sterile Processing

Front Door

Blood Bank

Day Surgery

IR

Sec3:94


Cardiac and Endo Procedures•

Cardiac and Endo Procedures -Admin•






PWC-PHHS Strategic Planning Document •


Invasive procedures include: cardiac catheterization, electrophysiology, •

including pacer and wire implants and cardioversions.

Non-invasive procedures include: EKG, Echocardiology, TEE. Invasive •

procedures include: Catheterization, Angioplasty, Pacer, ICD, Lead,

Electrophysiology and Ablations. Nuclear cardiology studies: Perfusion Scan,

MUGA Scan will be performed in nuclear medicine.

Background / Current-State

Invasive and non-invasive procedures currently have two different registration •

processes. Current registration is ineffi cient and results in 50% of patients

being no shows. Because of the high no show rate patients are scheduled at

150% capacity to compensate for the high no show rate and subsequent number

of procedures that area canceled.

Currently the cardiac services at PHHS are fragmented geographically. This •

geography impedes staff fl exibility and effi ciency.

There is inadequate procedure space, recovery space and teaching space. The •

restrictions caused by space cause procedural delays and bottlenecks.

Educating residents and fellows is diffi cult because of the fragmentation and the •

lack of dedicated conference room space.

Functional Narrative - Cardiac Unit: Invasive and Non-Invasive

Cardiology

Sec3:95


Model of Care:

In the future invasive cardiology and non-invasive inpatient cardiology will be co-located. •

The volume of non-invasive cardiac procedures has grown to the point that the cardiologists believe there is adequate •

volume to justify staffi ng two non-invasive cardiac services.

The future model will include 2 non-invasive cardiology services (1 inpatient based in the main hospital, 1 outpatient based in •

the clinic building).

It is imperative for accreditation reasons that the programs be one program in two locations. All staff (MD, tech and •

managers) will work between the 2 locations. Having two services will ensure that there is always a physician available in

the outpatient department. This will meet the cardiac rehab requirements of having a physician available in the building at

all times when patients are being treated.

All invasive procedures and inpatient procedures, with the exception of EKG, will be performed in the interventional platform. •

In the future all EKG’s will be performed bedside. •

All ICU ECHO’s will be performed at the bedside. Patients on the acute care units who require ECHO studies will come to the •

Cardiology suite in the interventional platform for studies.

Technology will allow ECHOs to be read in either the inpatient or the outpatient reading room. •

It is assumed that all services will operate 250 scheduled days a year, 10 hours a day, in addition to 24/7 availability for •

emergent procedures.

Invasive cardiology space and interventional radiology space is planned to be fl exible to accommodate volume shifts.•

This program also assumes that nuclear cardiology studies will continue to be the studies of choice. According to Cardiology •

faculty PHHS will not be moving to more advanced MRI/CT technology.

Recovery space will be shared with the interventional platform. This offers effi ciencies and economies, afforded by sharing •

staff, space and equipment.

PWC-PHHS board approved program recommended 2 cardiac cath rooms and 1 EP room. According to PHHS cardiologists •

a newly established invasive cardiac fellowship program and the new CT surgical program will increase volumes to justify 2

cath labs and 2 EP labs.

Two Cardiac Cath rooms and 2 EP rooms are planned. One EP room could be shelled until volumes increase. The •

cardiologists and VP believe that invasive cardiology volumes will increase with the development of invasive cardiology

fellowship program (new) and the development of a new CT surgical program.

Functional Narrative - Cardiac Unit: Invasive and Non-Invasive Cardiology

Sec3:96

Functional Narrative - Cardiac Unit Invasive and Non-Invasive Cardiology

Future Model of Care: Invasive Cardiology

Procedure Room

Recovery

IP Unit

Front office contacts patient, verifies

insurance. If a patient has no insurance and

the test is not emergent, the patient is referred to financial

counseling for funding. If the test is emergent, the test will

be scheduled. The patient will meet with financial counseling

post-procedure.

Referral placed

Entry Point

ED

Referral Origin:

IP Units

OP Cardio Clinics

Outside Hospital (Zales)

End Point

Morgue

Jail

Home

Pre-Procedure Day of Procedure

Pre-Procedure Evaluation

Consent obtained

Monday Before Procedure

Registration

Shared registration with Interventional

Suite

Sign in to procedure area

Pre Procedure Room

• Check out desk where follow up appointment can be scheduled will be located in the recovery space.

• Patients who do not have a support person present to take them home will be discharged to a supervised discharge lounge, where they can wait for their support person to arrive.

Sec3:97


Future Model of Care: Non-Invasive Cardiology

Sec3:98

Entry Point

ED

Referral Origin:

Units

OP Clinics

Outside Hospital (Zales)

End PointPre-Procedure Day of Procedure

Patient scheduled for procedure, given

pre-procedure instructions.

Insurance verified.

If test not emergent and patient does not

have insurance, patient receives

financial counseling.

Referral placed

Patient arrives

and registers.

Patient checks in at Cardiac

Desk

Recovery

IP Unit

Morgue

Jail

Home

Most procedures done in the ED

Prep areapatient change clothes, IV, etc.

ECHO

EKG(Bedside

for IP)

• HolterMonitor

• Stress Test

IV Room MUGA Scan

Hot room / Bathroom for patient Hot Room

TEE

Space Program:

Registration and Waiting• : Registration will be co-located with adjacent services- promotes effi cient use of staff and space

- Separate waiting spaces for inpatient and outpatient

- Most inpatients will go directly to pre-procedure area or procedure room

Pre-procedure area •

- Space will be single occupancy for privacy. There will be locked space for patient belongings

- Non-invasive procedures: patient goes directly to procedure room

- Space single occupancy for privacy. Locked space for patient belongings will be programmed

- Patient bathrooms will be programmed into this space

Diagnostic:•

- Stress Testing 2 rooms

- Echo 2 rooms will be programmed in the future (one to accommodate TEE)

- Reading rooms large enough to accommodate several readers, fellows, residents and students (6-8)

Cardiac Cath EP Labs: •

- Cardiac cath. lab and EP lab will be adjacent to each other

- 2 cardiac cath labs will be programmed

- 1-2 EP lab will be programmed

Control Rooms:•

- Spaced large enough to accommodate 6-8 people at a time for

- Layout confi guration will determine if there is one or multiple control rooms

- On any given day 3-4 fellows, + medical students and residents may be present for procedures

- Control room with large monitors is an optimal location for real-time teaching to take place

Recovery: •

- 6 recovery spaces will be programmed. These spaces will be private rooms, and equipped with telemetry monitoring

and gases.

- Patients who require prolonged recovery will continue to go to the telemetry unit.

Staff Work Space:•

- Charting stations with in the procedure rooms

- Centralized reading, control, conference space for collaborative teaming able to accommodate 20 people at a time

- Adequate waiting and registration space will improve process and make more effi cient

- Larger control rooms, reading rooms, conference room/ staff work space will improve teaching and patient outcomes

and make the process more effi cient

- Combining recovery with central or combined interventional recovery area will allow staff to be focused on other

procedures, increase room turn over time.


It is assumed that all services will operate 250 scheduled days a year, 10 hours a day, in addition to 24/7 availability for emergent

procedures.


Sec3:99


Adjacency Diagram

FUTURE FLEXIBILITY:

Flexibility: co-location of cardiac services with easy access to telemetry and CCU will improve effi ciency in fl ow and patient •

safety. Will allow staff to fl ex for coverage.

Sicker patients / patients requiring admission could go directly to CCU and bypass recovery / PACU•

One EP lab could be shelled and built out as patient volumes increase. •


Non-invasive

Cardiology

OP Cardiology

OR

ED

Cardiac Rehab

Cardiac Cath

IP Units

Nuclear Medicine

Interventional Platform

Sec3:100


Cardiac and Endo Procedures •

Cardiac and Endo Admin•







SCOPE OF SERVICES AND OPERATIONAL PLANNING:

The following procedures are performed in the GI Lab:

Endoscopies•

Colonoscopies•

ERCP•

Liver Biopsy•

Bronchoscopies•

Paracentesis•

The majority of the procedures that are performed are interventional and not •

screening procedures. The majority of the screening procedures are performed

at the Ambulatory Surgical Center.

The current GI lab is plagued by space constraints which promote ineffi ciencies. •

There is not adequate waiting space for patients so they end up waiting in the

hall, which is not private and violates HIPAA.

Ninety-fi ve percent of bronchoscopy procedures are performed at the bedside •

on inpatients.


Only 3 of the 6 GI labs can accommodate general anesthesia, which 30% of all •

patients require.

The smaller 3 rooms also are too small to accommodate ERCP procedures. •

Only 1 room has fl uoroscopy. This room is dedicated to bronchoscopy, but •

serves as an overfl ow room for GI procedures, specifi cally those that require

fl uoroscopy.

There are 22 GI fellows and 22 attending faculty who perform procedures. •

- Currently there are 4 GI fellows - being staffed by on attending MD doing

procedures at one time. The current space layout and confi guration

makes this staffi ng ratio diffi cult.

There are inadequate bathrooms for patients who have undergone bowel preps. •

Functional Narrative - GI Lab including Bronchoscopy

Sec3:101


Model of Care:

It is assumed that there will continue to be 35 GI faculty, of which 22 will continue to perform procedures in the GI suite. •

It is also assumed that PHHS GI will continue to fi ll their 22 fellowship slots. •

It is believed that the new colon cancer screening program will increase the volume of referrals to the GI suite. Thus, 8 •

procedure rooms were programmed instead of the 6 recommended by PWC

Liver biopsy and paracentesis have prolonged recovery times. They will be accommodated in the recovery space.•

Currently patients recover in the GI lab recovery space and are managed by the GI unit staff. This model of care results in •

staff being pulled to the recovery space, which takes them away from the procedure rooms. Even though the unit operates

for 10 hours a day, this includes recovery time. In the future these patients will recover in a dedicated recovery space by

dedicated staff, thus resulting in staff being able to be dedicated to procedures 10 hours a day- which will increase

procedural capacity.

Space Program:

Eight (8) GI procedure rooms at 480 NSF are planned. These rooms are large enough to accommodate GI fellow, attending, •

nursing staff, equipment, anesthesia and fl uoroscopy. Bronchoscopy procedures can be accommodated in any of the GI

rooms.

Entry:• Registration will be shared with interventional platform. There will be a back stage entry and separate waiting space

for inpatients.

Pre-procedure area:• Private spaces with bathrooms are planned and will accommodate patients who have had bowel preps.


Waiting space for Family.

Hours of operation: M-F 7am-5pm, M&F full day schedule, T&Th ½ day schedule

Test scheduled

Patients referred by GI, ED, Floor, JailAll are urgent

diagnostic tests no screening procedures

performed here.All referrals come to

Parkland and are triaged by RN. If

patient has any risk factors procedure

performed at Parkland if screening and no

risk factors scheduled in ASC.

ASC = 20k screening/ yr

Patient brought to

suite emergently

Patient checks in Procedure room:

• Sedated• Intubated• Procedure

performed• Extubated

Recovery room

Morgue

ICU

Patient D/C home

In patient unit

Jail

Patient sees financial counselor if necessary

Patient waits in the waiting room

Patient goes to pre-procedure room. Changes clothes, gets IV, consent

obtained.

Patient walks to the procedure room.

Patient taken emergently to procedure room

Sec3:102

Procedure rooms:• 5 general GI rooms are planned as well as 3 larger rooms to accommodate procedures requiring

fl uoroscopy.

Anesthesia workroom:• Anesthesia plays an important role in the care of patients during many of the GI procedures.

Anesthesia will have workroom space programmed into the interventional unit.

Recovery: • Recovery space will be shared with interventional platform. It is imperative that there will be adequate

bathrooms. Patients who do not have a support person present to accompany them home will be discharged to a supervised

discharge lounge until a support person is available to take the patient home. Follow-up appointments if necessary can be

made at the discharge check out.

Staff work space: • There will be decentralized work space for staff throughout the suite. Computer access to EMR and Pacs

will be available in each procedure room and physician/staff work rooms.

Provider workroom:• 1 physician work rooms / conference rooms with video telemedicine capabilities to watch procedures

from this remote location are planned. These spaces will provide space for GI teaching and patient management

conferences. Fellow and MD offi ce space is also planned.

Scope Cleaning: • One centralized cleaning room is planned. A 320 SF gross cleaning / decontamination room is planned. A

320 SF cleaning room is programmed. The cleaning area shall allow the fl ow of instruments from the contaminated area to

the clean assembly area and then storage. A 360 SF storage area is planned. This area will contain cabinets for scope

storage and accommodate a rotational pattern for scope use.


Assumes 250 scheduled days a year. Operates 10 hours a day.•

Assumes on call availability for emergencies 24 hours a day- 7 days a week.•


Department Hours of Operation % Procedures at peak day shift

GuidelinesHours of Operation

Administration 8 7.5 – 8

Endoscopy 8-10 plus call 90% 7.5 – 8

GI Laboratory 8-10 plus call 85% 7.5 – 8

Other 8-10 plus call 90% 7.5 – 8

X – Open 250 days / year Available for emergencies

Utilization / Hours of Operation


Sec3:103


The GI / Bronchoscopy unit should have the following vertical adjacencies: OR, ED, ICU (specifi cally MICU), acute care units •

and the front door.

Anesthesia will have work space within the GI / Bronchoscopy Suite.•

Adjacency Diagram


Sec3:104

Modality 2006 (Existing) 2012 2017 KHC Request

GI Lab & Bronchoscopy

Total Procedures, including Pulm.Bronch 7,637 9,130 10,170

Total Procedure Rooms 5 6 6 6 (3 with Flouro)

Less: Rooms in the ASC 0 -3 -3

Net Hospital Procedure Rooms 5 3 3

Hospital Prep / Recovery Beds 17 8 8

Total Procedures / Room / Year 1,473 1,522 1,695

Notes:Procedures include Colonoscopy, Flex. Sig., ERCP, Bronchoscopies, EGD, Endoscopic Ultrasound, and PEG only.Hospital Prep / Recovery beds assumes 2.5 per room.KHC per Texas Adm. Code � 1.5 Recovery per room

Pulmonary

Total Spirometry Procedures 5,037 5,579 4,740 Outpatient

Total Spirometry Rooms 1 1 2 Clinic Building

Volume Summary

GI (IP + OP) 6,095 8,114 8,109

Pulmonary Bronch (IP + OP) 5,427 6,348 6,966

Bronchoscopy (IP + OP) not including bedside 303 541 656

Room Requirements


Anesthesia

ICU

OR

ED

Acute Care Units

GI Lab

Front Door


Imaging / Radiology•








The Department of Radiology currently provides diagnostic x-ray, CT, MRI, •

nuclear medicine, interventional imaging, ultrasound services to inpatients and

outpatients. Currently there are 2 CT- scanners in the emergency department.

Services such as general imaging and ultrasound are provided at the bedside for •

patients deemed too ill to travel to the department.

In 2006 (9 months annualized- there were 327,134 studies performed. •

Current hours of operation by modality:

General imaging- 24/7•

CT- 24/7 •

Ultrasound 24/7•

MRI 24/7•

Interventional Radiology: M-F 6:30 AM - 5:00 PM and 24/7 on call•

Nuclear Medicine: M-F 7:30 AM - 5:00 PM and 24/7 on call•

Breast Imaging: M-F 7:30 AM - 5:00 AM•

Nursing staff is available in the department M-F 6:30 AM - 11:00 PM•


Model of Care:

It is projected that in 2017 the imaging department will perform 453,121 studies •

on inpatients and outpatients. These future inpatient and outpatient volume

projections were analyzed by PWC.1

The number of modalities to accommodate the volume and future capacity were •

projected. The current program was informed by the PWC document and

discussion with senior leadership and the Chair of Radiology. 2

1 Source: Kaufman Hall 2006 data (9months annualized), Price Waterhouse

Coopers(PWC) Volume Capacity, Projections. Master Facility Plan, June 2007.

2 Source: Kaufman Hall 2006 data (9months annualized), Price Waterhouse

Coopers(PWC) Volume Capacity, Projections. Master Facility Plan, June 2007.

Functional Narrative - Imaging

Sec3:105

In the future all imaging services will be performed in the main hospital building. •

The imaging center will need to be designed to accommodate both inpatients and outpatients.•

Mammography will be programmed in the outpatient building as it services only outpatients. •

Interventional radiology will be part of the imaging department not the interventional unit. Four (4) rooms are programmed. •

Recovery space is planned within the imaging department and will accommodate any imaging patient who required sedation

for an imaging procedure. Ten recovery spaces are programmed.

The current department is already digital allowing physicians to view studies remotely from any number of Pacs reading •

stations throughout the department and hospital.

In the future dictated reports will be integrated into the electronic medical record. •


Type Number of Machines

Diagnostic / R&F 7 general / 3 fluoroscopy

CT 6 (does not include ED)

PET/CT 1

MRI 6 (does not include NICU or OR)

Nuclear Medicine 7 (includes Nuclear Cardiology)

Ultrasound 10

Imaging Equipment List

Sec3:106

Space Program

Central Registration and waiting• : Registration will be centralized for the department in the future program. Eight (8)

registration booths are planned. This number was based on 95,803 patient visits annually, an average registration time of 15

minutes and a 12 hour operating day.

Each modality is programmed with support spaces specifi c for that modality. •

Gowned waiting:• One centralized gowned waiting space for male and one for female is envisioned.

Nuclear Medicine• : Space for 7 dual scanners, a hot lab and provider workroom with 4 PACS viewing stations are planned.

General Radiology and Fluoro:• Seven (7) general imaging and (3) fl uoro rooms are planned with reading spaces, (25) general

imaging reading spaces and (3) fl uoro are planned.

CT:• Six (6) 400NSF CT rooms with adjacent 140NSF control rooms are planned in the imaging department. An additional (3)

CT scanners are programmed to be within the ED space. The modalities in the two spaces should be in close proximity of

each other to allow staffi ng fl exibility and patient overfl ow.

MRI:• Six (6) rooms at 660NSF are planned. In addition (1) MRI will be located in the OR and (1) in the NNICU. The MRI space

has designated control rooms and reading rooms within this space.

Ultrasound:• Ten (10) ultrasound rooms at 172NSF each with adjacent reading space are planned. Rooms are sized to

accommodate two stretchers.

Reading Rooms: • Each modality has a designated number of reading rooms.

Anesthesia workroom• : Designated space to accommodate anesthesia MD who are covering cases requiring anesthesia or

sedation in the imaging suite is planned.

Administrative program: 10,587 DGSF is planned to accommodate MD offi ces, conference space, resident and fellow space •

and department administrative space.


Sec3:107


It is anticipated that the hours of operation will continue to be the same. The current hours of operation by modality are:

General imaging- 24/7•

CT- 24/7 •

Ultrasound 24/7•

MRI 24/7•

Interventional Radiology: M-F 6:30 AM - 5:00 PM and 24/7 on call•

Nuclear Medicine: M-F 7:30 AM - 5:00 PM and 24/7 on call•

Breast Imaging: M-F 7:30 AM - 5:00 AM•

Nursing staff is available in the department M-F 6:30 AM -11:00 PM•

Staffi ng:

The existing staffi ng plans are adequate for present volumes. The additional services that are proposed (PET- CT, additional

MRI, pediatric services) will require an operational plan for staffi ng.


The Department of Radiology currently supports imaging modalities in remote areas (ED, patient care units, OR) so vertical •

and horizontal adjacencies with effi cient access would be optimal.

Adjacencies to the patient care units for effi cient transport for patients who require testing on modalities that are not •

portable - MRI, CT.

Acutely ill patients may be present for imaging modality that is not portable, contrast reactions occur, sedation incidents •

are just examples of the emergencies that can occur in Radiology requiring Rapid Response or Code Team, thus easy

access from ED, ICU, OR are important.

Access to laboratory central receiving via p-tube or by person is important for the transport of specimens that are acquired •

during imaging procedure.

Adjacency and easy access to the outpatient building is essential as the majority of the non-general imaging studies are •

outpatient studies.

Adjacency Diagram


IP Units

Inmate Treatment

CenterPathology

Clinical Lab

Imaging

OR

ED

Sec3:108


Clinical Pathology•

Anatomic Pathology•

Morgue•

Blood Bank•







Lean Laboratory Models•


Clinical lab is responsible for specimen pick-up, receiving, and processing; Lab •

draws occur on the individual fl oors and units such as the ED and specimens are

then delivered via pneumatic tube or courier, with courier pick-ups scheduled at

two times per hour.

Anatomical pathology is concerned with the diagnosis of disease based on the •

gross, microscopic and molecular examination of organs, tissues and whole

bodies.

The Blood Bank: Is responsible for ABO typing and antibody screens, for blood •

and tissue typing. This lab is also responsible for ordering, obtaining and

dispensing blood products.

The primary functional laboratory areas include:

Clinical Pathology •

- Pathology Call Center: Sample receiving and phone question are fi elded.

- Phlebotomy Offi ce: Coordinated phlebotomy services.

- Specimen Processing Core Lab- includes send out.

- Core Laboratory: Chemistry / Toxicology, Hematology, Blood gas / Routine

coag, Urinalysis, Microbiology, Virology, Bone Marrow Special coag,

Referral Lab, Flow Cytometry, Immunology

Anatomic Pathology•

- Cytology Processing Lab

- Histology Lab- provides accessioning and grossing of surgical specimens,

tissue processing, production of slides and blocks in preparation for

reading

- The histology space includes a gross room, specimen storage, frozen

storage, saw room, and biocabinet for storage.

- Surgical Pathology-frozen section (See OR program)

- Molecular Pathology

- Morgue

Functional Narrative - Clinical Pathology/Anatomic Pathology/

Blood Bank/Morgue

Sec3:109

The primary functional laboratory areas cont:

Blood Bank: Is responsible for ABO typing and antibody screens, for blood and tissue typing. This lab is also responsible for •

ordering, obtaining and dispensing blood products.

Transcription•

Resident / Fellow teaching•


The Clinical Laboratory is currently located on the ground fl oor of the main hospital. •

Lab Central is located in close proximity to the Emergency Department. •

There are two smaller labs, storage space and offi ce space outside the main lab. •

There is additional refrigeration / freezer/ and small equipment storage in the PSA area close to the dock. •

Clinical lab is responsible for specimen pick-up, receiving and processing. •

Currently the department of Anatomical Pathology is located in several different geographical locations: Histology and •

faculty offi ces are located in Building 2EE, Gross Room and faculty offi ces in Building 2E and the Morgue located on the

ground fl oor of building D.

Pathology administration is the front door for the department and the hub of activity however pathology administration and •

support services are widely dispersed throughout the department (mainly on the ground fl oor).

There is no family space for body viewing.•

Pneumatic tube system is ineffi cient.•


Model of Care:

The future lab will support both inpatients and outpatients. •

Receiving should be easily accessible for couriers who deliver specimens. •

Pneumatic tubes should be networked through the new hospital and clinic building to provide easy delivery of specimens that •

can travel to the lab via a tube.

The core lab space should be designed to be Lean and support the specimen processing work fl ow from receiving, specimen •

preparation, specimen review and reporting and transcription.

-This will optimize operational effi ciencies.

The space should be open to incorporate a high level of fl exibility allowing for adaptation of equipment and processes as •

science and procedures change in the future.

- Movable furniture and open cabinets is preferable.

The lab currently has several biohazard hoods, high volume biohazardous waste disposable capacity, cylinder gas storage •

space, fl ammable liquid storage, room fume ventilation, slide block storage (secured room), reverse osmosis water system

all of which are programmed in the new space.

Equipment and reagents are temperature sensitive, thus adequate cooling and heating are required. •

The space must also meet security needs per Homeland Security regulations. •

Functional Narrative - Clinical Pathology/Anatomic Pathology/Blood Bank/Morgue

Sec3:110

The future Anatomical Pathology will continue to have 50 residents / fellows in their training program. •

-PHHS is the primary site for resident training.

-Because of the nature of the work that pathologists perform it is necessary to provide offi ce space- with microscopes

to accommodate all residents.

-Offi ce space is distributed throughout the department.

-The Morgue is a highly secured area.

-Two dissection rooms are planned in the morgue, one with negative pressure ventilation.

-The current cooler holds 8 bodies which is suffi cient. Shelving should be provided to accommodate infant bodies.

There is a secure viewing room for families programmed in the new facility. The morgue requires easy access to a

loading dock, where funeral homes may pick up bodies. A viewing room for next of kin is planned in the new space.

In the future electronic order entry and reporting will replace manual systems. The lab currently uses Cerner Millenium for •

its electronic reporting, in the future this system will be integrated with EPIC. It is envisioned that in the next 5 years all

dictations will utilize voice recognition technology.

Currently administrative staff employed by UTSW, who support AP faculty, have their offi ce space within AP department. •

This administrative space is planned in the new facility.


Sec3:111

Staff Support Space

Staff Lockers Staff Lounge

Education

Conf / Classroom

Wet Conf. Room

Scope Room

Pathology Administration

PathologistOffices

Team Work Area

Central Office Area

Workroom

Transcription

Mgmt Offices

File Storage

Lab Support

Glassware Washing

Walk-in Refrigerator

General Storage

Water System Closet

Flammable Storage

Clean Laboratory

Coats

Soiled Holding

EVS ClosetCardboard Breakdown & Recycling

Lab IS Server Closet

Courier Support

Clinical Pathology

SupplyPick-Up

Walk-up Windows &Staging Counter

Work stations

IP Phlebotomy Home base

“office”Work Counter Space (10

to 15 people)Orders Assigned

Employees Dispatched5 to 8am – 20

Phlebotomists / Trays

Processing Area for Core Lab

Bone MarrowSpecial Coag

Microbiology LabBacteriology

VirologyTuberculosis

MycologyParisitology

Infectious DiseaseMolecular (STD)

Pathology Services Center

(Call Center)(Stand alone with close

proximity to sample receiving. Needs P-Tube.

Can be shared, high acoustical privacy needed.)

Data link only

*Blood Bank, locate on Surgical Unit.

Core LabModular analytic system

“Spinning down”Cerner Thin Client

MicrobiologySample Receiving(Hand delivered & P-Tube)

Referral Lab

Flow Cytometry

Immunology Lab

Laboratory Support(See next page)

P-Tube

Microbiology Lab(Secured Area within Main Clinical Lab)

Blood Bank

Lab Information System (LIS)

Sample ReceivingReception

Staging(Bins, etc.)Storage

P-Tube

Offices & Work-

stations

DarkRoom

Scope Teaching

Room

Provider Workroom

Micro-bioEngineering

WasteDisposal


Sec3:112

Space Program:

Clinical Pathology

Sample Receiving and Supply Pick Up: • 1,130 NSF are planned for reception, receiving and staging of newly received

specimens.

Pathology Call Center:• 812 NSF, which included 8 call center workstations are planned for this space.

IP Phlebotomy Offi ce: • Coordination of phlebotomy services will be performed out of this space.

Specimen Processing for Core Lab: • 890 NSF are planned for this space. Specimens which need to be sent out to other

laboratories will be prepped, processed and packaged in this space.

Core Laboratory:• 15,638 NSF are planned to accommodate the core clinical laboratory services which include: Chemistry

toxicology and special testing, hematology, blood gas and routine coag. and urinalysis.

-This space should be designed to follow Lean processes. The space should be open and fl exible to accommodate

future process and technology changes.

Microbiology:• 5,816 NSF are planned to accommodate microbiology and virology. This space includes a 520NSF dedicated

negative pressure space to accommodate AFB processing. Teaching support space also provided.

Referral Lab: • a 306 NSF processing and receiving space has been programmed.

Flow Cytometry: • 648 NSF is planned, this space will accommodate 2 BD Facscalibur with SPA and resident and pathologist

space.

Immunology Lab:• 760 NSF is planned. This space is envisioned to be open fl exible benches where immunology testing will

occur.

Laboratory Support: • 760 NSF is planned to support glass washing, storage and water closet.

Anatomical Pathology:

Cytology Processing Lab: • Cytology is a biohazard laboratory. This space should be designed to be Lean and contain fl exible

open counter spaces. 990 NSF are programmed to support cytology functions. 1,416 NSF are programmed for cytology

administration. This space should be adjacent to the cytology lab.

Anatomic Pathology: • 2,596 NSF are planned. This space includes: accessioning space, grossing stations, saw lab, frozen

section, reading station, photograph station and storage.

Histology Lab: • 3,298 NSF have been programmed to accommodate histology processes.

Surgical Pathology and Cytology Transcription: This space includes 4 workstations for transcription.•

Faculty / Resident Offi ces: 1500 NSF has been programmed to accommodate 10 faculty in private offi ces, 8 resident work •

stations and administrative support staff.

Staff Support: 2,270 NSF have been programmed to support blood bank and anatomical pathology staff. This space includes •

a 400 NSF pathologist work room which contains a multi-head microscope (min. 25 heads) and a projection system. A 600

NSF conference room, staff break room locker space.

Blood Bank

4,541 NSF are planned for the bloodbank. •

This space includes: administrative offi ces, secure space for blood irradiation, specimen receiving, workstations for product •

testing, receiving, storage and walk-up counter and workstations for dispensing blood products.

There is 450 NSF dedicated to tissue management.•


Sec3:113

Morgue:

Public Space: 244 NSF is dedicated to waiting and family body viewing.•

Autopsy Area: includes 480 NSF refrigerated space; for 16 adult bodies.•

Staff support area: this space includes a small class room, 1 private offi ce, staff lockers and breakroom. •


Anatomical pathology M-F 6:30am-5:00pm and 24/7 on call•

Clinical Pathology 24/7•

Blood Bank 24/7 •

Staffi ng:

Staffi ng: * Pathology Administration will be in the Administration Building•


Clinical and Anatomical Pathology have requested that they be located next to each other to maximize fl exibility and work •

fl ow.

Internally, the Inpatient Core Laboratory has the following critical adjacency and proximity requirements:•

-Specimen Receiving / Send-outs and Blood Bank both require a close proximity or adjacency to a primary service /

support corridor to accommodate in-house and contract courier services access for delivery and pick-up.

-Specimen Receiving also requires a secondary adjacencies to Microbiology and Anatomic Pathology, unless there is

pneumatic tube service between them for specimen delivery.

-Specimen Processing area requires an immediate adjacency to both Specimen Receiving and an automated, 24 Hr.

Work Cell area (comprised of the major, high-throughput, multi-test Chemistry, Hematology, Coagulation and

Urinalysis instruments). Similarly, a secondary adjacency is required to a manual, 24 Hr. Work Cell area (comprised of

the non-automated, non-high-throughput Chemistry, Hematology, Coagulation, and Blood Gas instrumentation). An

additional tertiary adjacency is required to the Special Chemistry, Toxicology, Special Hematology, Flow Cytometry and

Immunology instrumentation.

-Blood Bank requires an immediate adjacency to the manual, 24 Hr. Work Cell’s Hematology instrumentation, due to the

sharing of some specimens. Blood bank and AP are programmed to share support space.

-Microbiology’s Virology, Molecular Microbiology and TB/Mycology/Parasitology laboratories do not need an immediate

or secondary adjacency to any other laboratory section, but should be immediately adjacent to the specimen receiving

and media preparation areas.

-Anatomic Pathology requires an immediate adjacency to the Molecular Pathology lab. It also requires a secondary

adjacency to Specimen Receiving area.

-Laboratory Support, Laboratory Administration, Staff Support and Education components require secondary and, or

tertiary adjacencies to all of the major technical areas of the laboratory.

The main laboratory should be easily accessible to Radiology and the OR’s. Frequently pathologists are requested to •

participate in diagnostic procedures in these departments.

There will be dedicated space in the operating room suite for frozen section/surgical grossing lab, in order to accommodate •

real time rapid microscopic diagnosis.

**The blood bank should be located between the OR and the ED with vertical adjacencies to both departments. This location/ •

adjacencies has changed since the program was signed off. Currently Blood bank is programmed in the OR and shares

support space with AP.

The morgue should be located in the hospital lower level and have access to a dock for funeral homes to pick up bodies.•


Sec3:114

FUTURE FLEXIBILITY:

The future space should be designed to be fl exible and adaptable. •

Science and technology will continue to advance and it is imperative that the lab be able to grow and adapt in relation to the •

changing fi eld of science.

As clinical programs at PHHS change a future expanded scope of laboratory procedures may be required. Genetics is a good •

example. Real time integration- genomics based translational science anatomical pathology may have an expanded role in

the clinical care of patients.


Sec3:115


Pharmacy•

OR Pharmacy Satellite•

ED Pharmacy Satellite•

ICU Pharmacy Satellite•



Identifi ed Best Practices: Lean approach, Robotics, Nurse server model of •

medication administration,





The Pharmacy provides the following services: ordering, procuring, preparing •

and dispensing of all medications for inpatient, outpatient (not public) and staff,

including all IV solutions and compounding of P&T approved medications.

Pharmacy services are currently located throughout the hospital and clinic •

building.

The pharmacy currently operates the following services: Pharmacy •

Administration, Central Pharmacy, Satellite Pharmacies, Drug information,

Investigational Drug Services, Sterile Products, ChempaK room and a Bulk

Stores area.

The department also manages the stocking of all Pyxis machines, this includes •

repackage bulk medications into unit dose.

Parkland’s pharmacy has a FDA license which classifi es it as a medical •

repackaging facility within the Prescription Center Pharmacy.

The pharmacy currently supplies outpatient medication to UTSW CV, heart and •

liver transplant patient.

The pharmacy also supports drug information, an investigational drug service •

and the mixing of all chemotherapy agents.

Background/Current State:

Pharmacy services are currently located throughout the hospital and clinic •

building.

Pharmacy Administration, Central Pharmacy, Drug information, Investigational •

Drug Services, Sterile Products, ChempaK room and Bulk Stores area are all

located in the basement of PHHS. Also in the basement are the Associate

Director and Coordinator offi ces, classroom and conference room.

Functional Narrative - Pharmacy

Sec3:116

Other pharmacy service locations are: Emergency Department satellite, Outpatient Clinic Pharmacy, Oncology and SICU •

satellite pharmacies, NNICU satellite pharmacy, L and D satellite pharmacy, OR satellite pharmacy, Med Specialty clinic

satellite pharmacy, Internal Med clinic satellite pharmacy, Transplant satellite pharmacy and the Medicine satellite

pharmacy, located throughout the hospital and clinic building. There is an HIV satellite pharmacy in Amelia Court and the

Prescription Center at 4911 Harry Hines.

Other pharmacy service locations are: Emergency Department satellite, Outpatient Clinic Pharmacy, Oncology and SICU •

satellite pharmacies, NNICU satellite pharmacy, L and D satellite pharmacy, OR satellite pharmacy, Med Specialty clinic

satellite pharmacy, Internal Med clinic satellite pharmacy, Transplant satellite pharmacy and the Medicine satellite

pharmacy, located throughout the hospital and clinic building. There is an HIV satellite pharmacy in Amelia Court and the

Prescription Center at 4911 Harry Hines.

The department has a contractual relationship with UTSW to provide discharge medications for cardiovascular patients, and •

heart and liver transplant patients.

The pharmacy manages all pyxis med stations.•

The pharmacy prepares all IV mixtures.•

The pharmacy prepares and dispenses all inpatient medications as unit dose.•

Robotics are currently used in the following locations:•

- A Talyst packer and Euclid tabletop packager are currently used; there is a horizontal carousel in the basement BSA

area.

- The IV room has a Baxa TPN compounder.

- A robot has been approved for inpatient drug distribution for FY 09.

The pharmacy also provides training to pharmacy students, technician students/interns and pharmacy residents.•

The current order entry and reconciliation system is totally manual.•

There is currently no dedicated IT system to over see PAR levels. A report is run 3 times a day to determine PAR levels. •

- Morris &Dickson is the wholesaler, but PHHS manages all inventory, receiving and procurement.

The department is 797 compliant.•

The pharmacy needs to follow class A, C and D pharmacy regulations.•

- PHHS has a FDA licensed medical repackaging facility within their Prescription Center Pharmacy which packages

medications for out Class D pharmacy locations.


Future Process Model:

The pharmacy will continue to operate as a Central Pharmacy, Outpatient Pharmacy (clinic building). The inpatient satellites •

will be consolidated to include only the NNICU satellite pharmacy (see NNICU program), ED satellite pharmacy, ICU satellite

pharmacy, OR satellite pharmacy, and Oncology satellite pharmacy (clinic building) in the new hospital.

The Oncology satellite pharmacy will be responsible for making all the chemotherapy for both the inpatient and outpatient •

areas. Because the Oncology satellite pharmacy is only open Monday – Friday during the day a backup chemo hood is

programmed in the Main pharmacy.

In the future all medication orders will be automated via the EPIC system. •

A robot has been approved in the FY 09 budget, for inpatient drug distribution.•

In the new hospital inpatient medication administration will be accomplished by use of a nurse server. •


Sec3:117


Bar code medication administration is becoming the future standard of care for safe medication administration. The •

Institute for Safe Medication Practices has petitioned the FDA to require bar coding on all medications. The bar coded

information would include NDC number, lot number and the expiration date.1 Further evaluation regarding medication

packing and bar code medication administration is needed.

The future design should separate the medical repacking facility within the Prescription Center Pharmacy, which currently •

repackages medications for all Class D pharmacy locations. In the future this space should be and independent but adjacent

space to aid in regulatory compliance.

The pharmacy must be 979 compliant.•

Future Process Model

1 Docket No. 02N-0204. Michael R. Cohen, RPh, MS, ScD at the Food and Drug Administration’s July 26, 2002, public meeting on bar code

labeling for drug products.

Sec3:118

The future inpatient pharmacy will occupy a space of 24,604 NSF.•

Product receiving:• a dedicated dock and breakdown area is planned

Storage and staging:• a 2,748 NSF space is programmed to be dedicated to storage and staging. Disaster drug / cache are

programmed into separate secure spaces.

Compounding and Packaging:• 3,448 NSF are planned and will include a narcotics vault, compounding area, staging space

which accommodates robots, hand pick areas for manual order fi lling.

Specialty cart/tray staging:• This function will be centralized in the future.

IV Preparation: • 979 compliant hoods, chemo mixing station, IV conveyor system. Future considerations would be for more

packing equipment to support bar code med administration and IV robotics.

Central Pharmacy: This space should be designed as a mini retail station and include drug storage, preparation •

workstations and a walk-up window.

Medical Assess: Open workstations are planned for data entry and inventory techs.•

Ordering and Procurement: Shared offi ces for 2 buyers and workstations for procurement and inventory specialist are •

planned.

Information Systems: In the future the pharmacy would like to explore the ability of EPIC interfacing with pyxis. An automated •

program for inventory and ordering management will be explored in the future.

Regulatory: Compliance with 979 and FDA regulations for Class A, C and D must be followed.•

Satellite Pharmacies: OR, ED, ICU satellite pharmacies are planned. Each pharmacy is programmed to be 896 NSF and •

include spaces for ordering processing and pick-up, storage and staging, compounding and packing and specialty care/tray

staging.


Sec3:119



Position or Title Inpatient Ambulatory PharmacyAdmin.

Pharmacy Systems

Procure-ment

Inventory Control

JailHealth

Repack Benefits

Director 1

Assoc. Director 1 2 3 1

Coordinator 4 9 2 1

Clinical Specialist 5 9 1

Staff Pharmacist 70 69 5 4 1 6

Pharmacy Tech 85 54 4 3 5

Mess Aide 2

Billing Manager 1

Sr. Med Access Spec. 1

Med Access Spec 15

Data Entry Operator 1

Inventory Tech 1

Business Analyst 1

Administrative Assistant 3

Perf. Imp Specialist 1

Clin.Drug Usage Analyst 1

Med Safety Officer 1

PGY1 5

PGY2 1

Inventory Coordinator 1

Procurement Assistant 5

Buyer 1

Sec3:120

Hours of Operation

Main Pharmacy: 24 hours a day – 7 days a week•

Inpatient Satellite Pharmacies: 24 hours a day – 7 days a week •

Pharmacy administration: 8:00am-5:00pm Monday - Friday •


The pharmacy will be responsible for stocking pyxis machines and nurse servers on the patient care units.•

- Clinical pharmacists will continue to be an integrated part of the patient care team. With the implementation of EMR

the pharmacist will be able to have a more involved role in the clinical / pharmacologic management of patients.

The pharmacy has a MRD related support role in collaboration with respiratory therapy, imaging and care management.•

Pneumatic tubes will provide additional connectivity with patient care areas. •

Adjacency Diagram

Care Mgt.Patient Care Units

Radiology

Respiratory Therapists

Central Pharmacy

IT –Telecom -

DPS


Sec3:121

FUTURE FLEXIBILITY:

Opportunities for improved operational effi ciency and lean approach with regard to work fl ow, automation and patient safety •

should be explored.

Designing for the highest possible level of standardization and exploring open layout and modularity to ensure future •

adaptability as equipment and processes change should be considered.


Respiratory Care•

- This functional narrative addresses only the inpatient program and

functions.








Respiratory care services are provided in both the inpatient and outpatient •

settings.

Respiratory care provides services to patients throughout the hospital. •

It is assumed in the future that RT will be dedicated to fl oors or units and thus •

have dedicated workspace within the fl oor core or unit.

Respiratory care provides a variety of services including: airway clearance •

maneuvers, such as chest physiotherapy, nebulizer and meter dose inhaler

treatments.

They manage all invasive and noninvasive ventilation throughout the hospital.•


The inpatient Respiratory Care program is 3,472 NSF and includes:•

-1,224 NSF dedicated to equipment

-1,880 NSF dedicated to administrative space, including dedicated teaching

space to accommodate respiratory therapy students.

-368 NSF dedicated to staff support

The following spaces are dedicated to respiratory care and are not included in •

the respiratory care program. They are included in the patient are programs

listed below.

-In addition to bottled gas storage, 144 NSF is programmed in each unit

fl oor core (10) as dedicated respiratory work space.

-400 NSF is programmed in the NNICU as dedicated respiratory work

space.

-100 NSF is programmed in the inmate treatment unit as dedicated

respiratory work space.

-100 NSF is programmed in the ED as dedicated respiratory work space.

Functional Narrative - Respiratory Care

Sec3:122


Sec3:123


The main respiratory care department needs adjacency to biomedical engineering.•

Discussion re. placing this department or the storage / repair function of this department with Central Logistics.•

The administrative space could be collocated with PFT and the non-invasive home ventilatory program managed by RT. •

Theses functions will be in the clinic building.

FUTURE FLEXIBILITY:

The placement of the storage / repair function of this department with Central Logistics offers future fl exibility.•

The placement of administrative space collocated with PFT and the non-invasive home ventilatory program managed by RT •

offers future fl exibility and adds cohesiveness to the department.


Main Lobby•

Women’s Lobby•


Proven evidence-based design.•

Identifi ed best practices. •


PHHS input.•


Current lobby serves as the main entrance to the hospital and is open 24 hours a •

day.

Main lobby houses reception, information and waiting services. •

Women’s lobby and reception desk exists, but is not staffed nor located so that it •

is well utilized for this purpose.


Lobbies will be points of orientation for the hospital and will address security •

and waiting functions.

Lobbies will provide opportunities for positive fi rst impressions for all who enter •

and should be clearly visible with easy access upon arrival to the hospital

campus.

Each lobby in the new facility is programmed to be approximately 4,441 DGSF. •

Space includes a large information desk, which should be centrally located and •

is sized at 160 NSF to accommodate 2-4 staff workstations.

Open hotel type seating at approximately 600 NSF is planned to accommodate •

waiting.

Child friendly seating that is easily cleanable.•

Public male and female restrooms with diaper changing areas•

Access to the main set of public elevators with clear line of sight from the entry •

or reception area for optimal way fi nding.

Wheelchair, including bariatric wheelchairs will be stored in close proximity to •

the entrance.

Minimize cross traffi c and congestion with either of the lobbies and the •

emergency department entry or the loading docks.

Security at each entrance to the fl oors will be provided, although security •

offi ces/headquarters are located in another building.

Functional Narrative - Main Hospital and Women’s Services

Lobbies

Sec3:124


One central entrance is planned for all services except woman’s services. •

Separate entrance is planned for woman’s services and should tie to the bank of elevators that travel to the women’s and •

infant patients fl oors.

Women’s lobby must be adjacent to a drop off with short-term or valet parking for the arrival of women in active labor. •

Central and secure entrances will be open 24 hours a day. •

Space should be designed as the greeting space. •

Visitors and patients should have a convenient path from the gift shop and chapel to the Main Lobby.•

Clear orientation and wayfi nding should be provided to the lobbies for arrival and departure from parking structures, DART •

and other transportation areas.

FUTURE FLEXIBILITY

Lobbies were programmed with options in mind about their proximity and location, which will be developed further during •

the design phase. Discussions included locating them at opposite ends of the main fl oor, on two different levels due to grade

differences, and as two separate lobbies along a shared drive using an “airport” arrival design model among other ideas.

Functional Narrative - Main Hospital and Women’s Services Lobbies

Sec3:125


Patient Navigator / Discharge Lounge•








The need for a solution to the discharge process of inpatients has been •

identifi ed. Many times patients are medically cleared for discharge, but there is

a lingering social problem: placement, fi nancial / funding for prescriptions,

access to transportation.

PHHS is creating a new service: a Discharge Lounge.•

This service will provide a place for patients to wait while they are waiting for a •

ride home or accessing the pharmacy for prescriptions, supplies, or meeting

with fi nancial counselors, case managers or social workers to arrange follow-up

care.

A professional level staff member will be present to facilitate follow-up •

appointments and care arrangements.

The success of this service will be assessed by the availability of inpatient beds.•


1,747 NSF are planned to accommodate the Discharge Lounge.•

This space will accommodate seated / wheelchair including bariatric, waiting •

space for 24 patients.

Four workstations and (2) private offi ces are planned to accommodate patient •

related appointment, fi nancial needs, etc.

Staff support space is also planned for this space.•

Functional Narrative - Patient Navigator / Discharge Lounge

Sec3:126


The discharge lounge should provide easy access to the eligibility center and pharmacy.

FUTURE FLEXIBILITY:

The addition of the discharge lounge service should provide increased and bed fl exibility.

Functional Narrative - Patient Navigator / Discharge Lounge

OR / Recovery

Interventional Unit

Pharmacy Discharge Lounge

Patient Care Units

Sec3:127


Patient Relations•

Interpreters•








The Patient Relations Department functions as an advocate for patients and •

serves to ensure that patients and their families have a good experience at

Parkland Hospital and Health System. Patients and families access these

services by telephone, email, written correspondence or by walking into the

department.

- Patient satisfaction is of paramount importance as it ensures that patients

are satisfi ed and will most likely return to Parkland Hospital when they

require additional medical services.

The interpreter service provides interpreter and translation services for non-•

English speaking patients and families. Currently there are 34 Language

Assistants who work directly with patients and families. The Language

Assistants work throughout the inpatient and outpatient areas. Back-up

services are provided through a telephone language line.

The current space is not adequate to support both Patient Relations and •

Interpreter Services.

The Patient Relations Department is planned to be located within the hospital, •

although there has been discussion about moving the space to the clinic

building, if easy access to the hospital can be maintained.


The Patient Relations Department and the Interpreter Services can be co- •

located but each service needs individual space to support departmental and

staff functional and operational needs.

Approximately 1,384 NSF is planned for the Patient Relations Department. This •

space includes reception and waiting space for patients and offi ce space for

staff.

The Interpreter space is 1,032 NSF and includes touchdown space for Language •

Assistants and private offi ces for patient advocates. Additional space is provided

on the patient care units in the form of hoteling space which is shared among

those staff who are mobile.

Functional Narrative - Patient Relations and Interpreters

Sec3:128


These departments support the entire institution and can do so from any location. •

The Patient Relations Department needs to be located in a place that is easily accessible to patients and families. •

The Language Assistants need to be able to easily access all inpatient and outpatient care spaces where there services are •

currently used.

Functional Narrative - Patient Relations and Interpreters

Sec3:129

Functional Narrative - Gift Shop


The Gift Shop at Parkland Hospital has been serving patients and visitors since •

1941.

The Gift Shop is currently located in the lobby on the fi rst fl oor of the hospital •

and is open Monday thru Friday 9:30 AM to 5:30 PM and from 10:00 AM until 4:45

PM on Saturday and Sunday.

The Gift Shop, staffed by approximately 6 FTE’s, sells toiletries, food items, gift •

and novelty items and realizes approximately $200,000 in annual sales.


A new Gift Shop was programmed for the hospital and is approximately 2,340 DGSF.

Requests were made that the program include:

A dedicated rear entry for deliveries if possible•

Space for fl oral and beverage coolers•

Helium storage•

Retail shelf space•


The Gift Shop should be located in a high traffi c area.

Sec3:130


Cafeteria / Dietary Services / Formula Room•








This program is sized to support for a 988 bed hospital and the adjacent clinic •

building.

This program does not include clinical dietician work space, this space has been •

included in the teaming space on the inpatient care units.

The formula room is included in the NICU.•

The cafeteria will provide food for purchase for family and visitors during regular •

hours of operation.

A room service / made to order model was presented to PHHS dietary staff and •

leadership. The decision to continue with a pre-selected menu was made.


The formula room will be located with in the NNICU.•

26,827 NSF are planned to accommodate a dining room, servery area, loading •

and receiving, refrigerated and frozen storage, bulk production area, patient

meal staging, ware washing and administrative support space (clinical dietician

home base).

The programmed space affords maximum fl exibility so that a food services •

consultant during the architecture phase will have needed SF.


The cafeteria should be located in a highly visible space. •

The cafeteria should be easily accessed and off a main corridor. •

The cafeteria / food service requires access to an outside dock.•

FUTURE FLEXIBILITY:

The programmed space affords maximum fl exibility so that a food services •

consultant during the architecture phase will have needed SF.

Functional Narrative - Cafeteria

* It is assumed that a Dietary Consultant will be involved

with the architecture and design of this space.

Sec3:131


ADT & Patient Flow•

PLANNING WAS INFORMED BY THE FOLLOWING:PLANNING WAS INFORMED BY THE FOLLOWING:



Completed Staff Questionnaires•

Price Waterhouse Cooper- PHHS Strategic Planning Document •



The Admission, Discharge and Transfer Department (ADT) operates 24 hours a •

day 7 days a week and is responsible for bed management, which includes the

coordination of all admissions, including those referred from other hospitals and

EMS, internal patient transfers and discharges.

ADT is reliant on technology for every aspect of their work. All departmental •

applications are computer based. TeleTracking ® is the software package that

Parkland Hospital currently uses and plans to use in the future for managing

ADT patient fl ow and maximizing bed capacity.

Currently the hospital has multiple operational and space related issues that •

lead to ineffi ciencies with regard to patient fl ow throughout the institution. Often

patients wait in the ED for hours before a bed is available. Patients who have

been discharged currently wait in their rooms for family members for

transportation. These practices create delays in the room availability. While

these operational and space constraints are not the direct responsibility of ADT,

they impede ADT’s ability to effi ciently move patients throughout the institution.

Background/Current State

The ADT staff is satisfi ed with their current space and have asked that the •

program for the new hospital refl ect their current practices and space

confi guration. Space should be planned as a bullpen arrangement of

workstations that are in close proximity to each other for ease of

communications.

The work space also requires a view of the bed board. The transfer coordinator •

work space should be located in close proximity to the bullpen, but provide

acoustical privacy to support phone work. “Off-stage” work areas have been

planned for the patient fl ow coordinators and the admitting nurse to allow for

confi dential patient conversations

Functional Narrative - ADT

Sec3:132

ADT offi ce at PHHS - this space works well.


The Joint Commission of Hospital Organization’s, revised standard, LD 3.15 addresses patient fl ow throughout the hospital •

and became effective January 1, 2008. The standard charges hospital leadership with “developing and implementing plans

to identify and mitigate impediments to effi cient patient fl ow throughout the hospital.” 1 This standard requires hospitals to

have policies and processes to address patient fl ow and safety throughout the organization. In addition to operational

changes many institutions have developed discharge lounges and clinical decision units to facilitate more effi cient patient

fl ow.

Automated patient tracking systems, like the one that Parkland is currently using have proven effective in improving the •

movement of patients throughout the institution. A total electronic environment including EMR and order entry is planned

and will enhance this process.

Hours of Operation:

24 hours a day – 7 days a week •

- safety and security of staff during the “off-hours” must be taken into consideration.

The future Parkland hospital includes a discharge lounge and a clinical decision unit, both of which should enhance bed •

availability. The implementation of a total electronic environment in conjunction with the TeleTracking ® system will make

the current ADT process most effi cient in the future.

1 The Joint Commission’s patient fl ow leadership standard, LD.3.15


Sec3:133



The patient fl ow coordinators spend considerable time as they work to coordinate of the admission and discharge process:

on the patient care units,

in the ED

A convenient location within the hospital that allows for easy access to the patient care areas is essential.

The ADT Department should have a close adjacency to the discharge lounge, which will allow effi cient follow-up with patients

who may have lingering discharge needs.

Adjacency Diagram

FUTURE FLEXIBILITY:

The future vision of an electronic environment will greatly enhance the role of the ADT coordinators in addition to allowing them

to do their work remotely or centrally throughout the institution.

DischargeLounge

ADT Office24/7

Patients waiting for bed. Do

they share the Discharge

Lounge? What about Immun. Compromised

patients?

Same Day Admit Patient

IP BedAvailable

Bed Available

Bed Not Available

Patient Flow Coordinators

(3 staff)4a to 10p

Visit IP Units multiple times daily

Hotline Nurse(M-F Peak)

ADT Staff“Phone” Work

AreaCall Center

Lounge & Restroom

ADT Call Center and Patient Flow Coordinators need to be co-located. Patient Flow Coordinators must be located in the Main Hospital for patient access. ADT Office needs to be located ‘backstage’ within the main hospital.

Can be same space acceptable, acoustical separation needed

Conference for 7 people

Management Offices (See Survey)

* How does this relate to ED patients waiting for beds?


Clinical Decision

Unit

IP Units

ED

PACU

D/C Lounge ADT

Sec3:134


Medical Records•








The medical records offi ce provides birth certifi cate information for patients •

born at PHHS and release of information for the receipt of medical records.


1,404 NSF is planned for this space, which includes waiting space, work stations •

and offi ce support equipment space.


This space services in and outpatients and should be easily accessed from both •

the in and outpatient areas..

Functional Narrative - Medical Records

Sec3:135


Eligibility Center•








The eligibility center helps patients navigate and apply for programs such as •

medical assistance.


1,824 NSF are planned for this space, which includes waiting space, eligibility •

work stations and offi ce support equipment space.


This space services in and outpatients and should be easily accessed from both •

the in and outpatient areas.

This space should be in close proximity to the discharge lounge.•

FUTURE FLEXIBILITY:

The services provided by the eligibility center are critical to the funding and •

ability of many of PHHS cliental to receive medical services.

Functional Narrative - Eligibility Center

Sec3:136


Chaplaincy•

- The chapel will be programmed at approximately 1,124 NSF and includes

space for seating 60 people. A meditation room adjacent to the chapel is

also planned.









The Pastoral Care Department at Parkland Hospital and Health System is a •

multi-denominational ecumenical ministry. In addition to being supported by the

hospital it is supported by multiple community churches and agencies.

The chaplain is part of the healthcare team and plays an important role in •

guiding the patient with regard to ethical, religious and spiritual issues.

A chaplain is available in the hospital 8:3 AM until 5:00 PM, Monday thru Friday •

and is on call 24 hours a day.

The hospital’s chapel is open 24 hours a day for purposes of prayer and •

meditation.


Model of Care:

The Pastoral Care Department requested co-location of three elements of their •

work: the chapel, pastoral care administration and the clinical pastoral

education program.

The chapel and the pastoral care administration will be located within the new •

hospital space.

The education program will be located in the new administrative offi ce building. •

This space includes 2 private offi ces, 12 work stations for clinical pastoral

education students, a small private conference room with seating for 8 and a

large conference room programmed to seat 20 individuals.

Functional Narrative - Chaplaincy

Sec3:137

Space Program

Administrative offi ce• space for the Pastoral Care Department will be located adjacent to the new chapel and is programmed

at approximately 1,292 NSF.

This space should be accessible to families and be designed to offer privacy to families who seek services in times of grief. •

Nine private offi ces• for priests and pastoral workers are planned. These spaces can be use to meet with families.

A • small nourishment room with seating for 12 is also planned.

A • bereavement room is planned within the emergency department space.

Private consult rooms• are planned on the patient care fl oors and can accommodate private space to meet with families.

There will also be hoteling space on each care unit that pastoral counseling staff may use.


The chapel should be conveniently located with easy access to the patient care areas.

Adjacency Diagram

FUTURE FLEXIBILITY:

The Pastoral Care Department currently provides a large array of supportive and educational services to patients, families and

the community. Providing space for these services in the administrative building will allow the programs the spaces for

expansion.

Functional Narrative - Chaplaincy

Volunteer ServicesIP Units

Social Work

Body Viewing

Pastoral Care

ED

Sec3:138


Employee Lactation Rooms•


Proven evidence-based design.•

Identifi ed best practices.•



general consensus.


Provide appropriate facilities for breast pumping women who are part the PHHS •

workforce, including employees, residents, faculty, volunteers and others.


PHHS supports breastfeeding patients; teaches classes to expectant mothers •

and is a recipient of grants to support community-wide efforts to increase

breastfeeding rates.

PHHS provides pumps and limited space for staff to breast pump on-site and •

indicated in user group meetings that there is a strong desire to improve this

situation.

PHHS was not listed as one of the hospitals on the Texas Department of State •

Health Services (DSHS) with “Mother-Friendly “designation. Presbyterian,

Children’s and Methodist are designated Dallas area hospitals, according to a

recent view of this list that DSHS is required to provide to the public. (www.dshs.

state.tx.us/wichd/lactate/mother-worksites.shtm website was checked 3-18-

2009).

DSHS administers the Mother-Friendly Worksite Program created in 1995. •

PHHS would need to provide work schedule fl exibility to allow time for pumping

breast milk or nursing infants, offer a private space for women returning to work

or new hires to either pump or nurse, and ensure easy access to clean running

water and refrigeration. An application with the policy must be submitted to

DSHS.


Spaces and equipment for breast pumping should be dispersed throughout the •

hospital and clinics.

Research supports both the health benefi ts and business benefi ts. •

Breastfeeding mothers are 50% as likely to miss a day of work for a sick child

compared to mothers of formula feeding infants. (Cohen, Mrtek & Mrtek, 1995)

Texas Instruments, Cigna and many other companies have reported benefi ts that •

are posted on the DSHS website:

“We believe this program offers a win-win situation. Breastfeeding results in •

healthier babies, which leads to less absenteeism for parents and reduced

medical costs and more productive employees.” ~ Betty K. Purkey, Texas

Instruments

Functional Narrative - Employee Lactation Rooms

Sec3:139

Best practices at Cigna attributed annual savings to their lactation program in the amounts of $240,000 in health care •

expenses, 62% fewer prescriptions, $60,0000 saved in reduced absenteeism rates (Dickson, Hawkes, Slusser, Lange, Cohen

& Slusser, 2000).

Space Program:

Ten employee lactation rooms with sinks to be dispersed throughout the hospital. •

Additional rooms for clinic and offi ce buildings are excluded from this program.•


Availability 24 hours a day - 7 days a week.•

Anecdotal information was provided in the absence of data regarding need.•

Staffi ng:

Cleaning, organization and management of the rooms will be required, but the space does not need to be staffed. •

Information on the responsibilities for tasks associated with these rooms was not defi ned during programming.


PHHS indicated preference for dispersion throughout facilities for staff convenience and productivity, rather than •

centralization of these rooms.

Facility layout will help identify appropriate locations during the design phase.•

Functional Narrative - Employee Lactation Rooms

Sec3:140


Central Sterile Processing•

-14,430 DGSF are programmed for the Central Sterile Department in the

new hospital.








Sterile processing is responsible for the cleaning, decontamination, sterilization •

and inspection of all surgical instruments, devices and implants for the inpatient

and outpatient areas at Parkland Hospital.

This department is also responsible for controlling and monitoring medical •

devices.

SPD plays a critical role in maintaining patient safety and infection control •

practices.


Currently there are multiple decentralized sites at Parkland where sterile •

processing takes place.

The current process is manual, ineffi cient and results in delays. •

There is no instrument tracking system which results in the loss of expensive •

equipment.


Model of Care:

Sterile processing will be consolidated into one centralized department. •

With the exception of endoscopes and fl exible bronchoscopes, which will be •

cleaned in the GI suite, all instruments requiring cleaning, decontamination and

sterilization will take place in one centralized location.

This space should be designed to accommodate Lean-thinking and should •

support a 3-zone linear fl ow design concept- soiled to clean to sterile, and

feature pass-thru sterilizers.

A case cart system will be implemented. This system will be supported and •

driven by the surgery and procedural area information systems. The future

requisition process will be automated, streamlined and timely.

The case carts will be assembled by Sterile Processing and delivered to the •

sterile surgery core area.

Adequate space is planned in the operating room suite to accommodate two •

case carts per OR.

Functional Narrative - Central Sterile Processing

Sec3:141

A rotation system will be employed as cases are completed in surgery. •

Clean carts will be transported via a clean elevator and used carts with soiled instruments and trays will be returned via a •

soiled elevator.

There will be a designated and labeled location for all supply, equipment, and instrument containers; the case cart fl ow •

process will inform the internal locations for these functions.

Bar coding will be used for identifi cation and tracking. •

A wireless system will be used for case carts; this is expected to reduce demand redundancies, and a tracking system will •

inform accurate demand forecasting

General instrument trays will be standardized, assembled in containers, and processed in a sterile processing area, adjacent •

to the case carts. These provide at least 90% of necessary instruments.

General Instrument trays will be handled in a manner equivalent to the Sterile Processing model.•

Additional instruments, such as clinical specialty or surgeon specifi c items, will remain in the department, in a centralized •

location.

A bar coding system will also be utilized for instrument tracking and location.•

The supply process primarily relies upon a case cart system. However, some supplies will be stored in the surgical suite, •

with easy access for surgeons/staff during surgery. Case carts will be used for the delivery of necessary supplies.

The carts will be stocked with general instrument trays, ordered in advance of the procedure. •

More specifi c carts will be stored in a central location.•

Space Program:

The Sterile Processing department will be located on the ground fl oor of the new hospital and will require a vertical •

adjacency to the operating room, c-section and imaging spaces.

Dedicated clean and soiled full size elevators for delivery and pick of case carts and supplies is planned. •

The department should be easily accessible to vendors from the outside. •

Assembly will occur at a central counter, with 3 - 4 workstations, each equipped with a lighted magnifi er, compressed air, and •

video monitors attached to the surgery information system.

Pathways to ensure mission critical instruments are functional and not damaged will be in place, and a bar coding system •

will be utilized for instrument verifi cation and location.

The equipment list includes 2 Large Steam sterilizers, 2 Sterad Sterilizers, 4 Ozone Sterilizers, and space for 120 carts is •

planned.

Stations with medical air, light source, video monitor, lighted magnifi er, demagnetizer, and other bio med devices should be •

located in the surgical suite with ready access for technical support staff.


Sec3:142


A vertical adjacency to the operating rooms is essential, clean and soiled elevators are planned. •

Easy access to all patient care units, the Emergency Department, cardiac catheterization and the clinic building will be •

important for the transport of equipment.

Adjacency Diagram


L&D

ClinicsIP Units

Vendors

Central Sterile

Processing

Cath Lab

ED

ASC?Central

Equipment Garage?

Sec3:143

Key Room Diagrams and Room Data Sheets



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