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TENCONSIDERATIONS WHEN RENOVATING YOUR

patient TOWER

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© Scott Pease

© Kevin G Reeves

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While the many benefits of caring for patients within a private room have been understood for decades now, there are still thousands of patients who still receive care outside of this clinically preferred environment on a daily basis. As is often the case, the benefits may be clear, but the perceived cost of providing more private patient rooms has prevented the wholesale adoption of this basic principle throughout the United States. Building new bed towers has been an option for systems that could afford the construction costs, however, many hospital systems do not have that luxury or are landlocked and cannot expand.

In addition, the uncertainty of the Affordable Care Act reimbursement landscape has certainly contributed to stalling the move toward 100% private rooms.

On the surface, the alternate solution should be readily apparent. The trend toward outpatient care continues to limit inpatient stays, thus reducing the number of required beds in many areas of the country. So why not simply remove one bed from each semi private room while this might be the expedient solution, as is often the case, the expedient solution may not be the most appropriate solution.

There are a variety of considerations that need to be thoughtfully addressed when converting semi-private rooms to private – and more often than not, some level of physical alteration is needed to address these issues. Recognizing “necessity is the mother of invention,” the Array Thought Leadership team developed this top ten list of considerations to help healthcare organizations develop effective plans when considering renovating/converting semi-private bed units into private bed units.

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operational efficiency considerations

Conventional wisdom historically has supported the notion that a typical medical/

surgical unit operates most efficiently within a range of 24 to 36 patient beds per

unit. Depending upon the size of the existing unit, it can be challenging to achieve

these ideal ratios when converting to all private room model.

By implementing Lean Design principles with your architect during design, you can

identify potential staff inefficiencies posed by the renovation. This includes activities

to help users see through a new set of lenses and redesign processes for maximum

efficiency. In essence, the work is addressing the fundamentals of what happens

in the workplace to ensure all the resources or “flows” come together in the right

place, in the right quantity and at the right time to support the care provided without

error. The last thing you want to do is renovate your patient floors to reflect the “work

arounds” your staff has developed.

Lean activities include on-site observation and preparing spaghetti mapping

diagrams to identify existing bottlenecks, so that a virtual optimized “future state”

can be developed. Utilizing a Lean Design approach allows the design team to fully

understand the operational issues that must be supported in the renovated space.

Your design team should match their methods to the healthcare organization’s level

of lean proficiency. Your architect should assess factors, including client leadership

beliefs and approach to workflow improvement, the existence of infrastructure to

support process improvement and the ability of the design team to collaborate and

integrate lean concepts. The assessment should drive the scope of the work.

••• Misalignment of the care model and the physical layout can mean a design that doesn’t support the way staff work and could even inhibit them.

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logistical considerations

It is tempting for hospital facilities to simply change the door signage of a semi-

private room, paint the walls and call it a day. But experience has demonstrated that

this is not a long-term solution due to the impact on the operational model when

converting to a private bedroom model.

More often than not, physical alterations are required in order to facilitate efficient

operations of a transformed inpatient care unit. The artistry is in determining the

appropriate level of renovation required, and in developing a plan to effectively

execute the renovation in a manner that minimizes any disruption of the day-to-day

hospital operations. The specific circumstance of any given renovation situation will

drive many of the detailed decisions, but there are common elements that transcend

these variations.

For example, the proper phasing of a renovation project is essential to its success.

Assuming there are a number of floors to be renovated in a single wing, there are

choices that can be made to limit the impact of the construction on the operations.

For instance, it may make more sense to renovate a few rooms at a time on multiple

floors (stacked together) as opposed to closing down an entire floor for construction.

This stacked phasing model allows the above ceiling construction to occur in a

single area without the same above ceiling disruptions that occur when renovating a

horizontal wing – one floor at a time. Building Information Modeling (BIM) can be used

to assist in the modeling of renovation scenarios by adding a 4D element (time) to

simulate the sequencing of construction, thus enabling stakeholders to make better

decisions when developing and finalizing the construction phasing plan.

••• Vertical Stacked Phasing

••• Horizontal Stacked Phasing

© Scott Pease

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life safety considerations

Providing a safe environment for patients, staff, family and

visitors is clearly the utmost priority – and responsibility - of

any healthcare organization. Turning an operating nursing

unit into a temporary construction site creates numerous

environmental challenges that can only be addressed with

proper planning and execution of a well-conceived plan that

incorporates proven interim life safety measures (ILSM).

A properly planned and executed ILSM will result in zero

disruptions to patient care and hospital operations. In basic

terms, “life safety measures” are health and safety features

designed to protect the safety of patients, visitors and staff

who work in the hospital facilities, including specific safety

features such as egress corridors, exit signs, fire protection

systems (smoke detectors, sprinklers, fire extinguishers and

fire alarm systems), smoke barriers, emergency evacuation

plans and many other items.

These features are often compromised during construction

within an operating facility, so the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) developed

Interim Life Safety Measures to protect the safety and health

of patients by compensating for any hazards caused by

construction activity.

There are main steps in the planning and implementation of

ILSMs: (1) Pre-construction Assessment, (2) Development

and Daily Monitoring of an ILSM Compliance Checklist and (3)

Close-out of the ILSM to transition back to standard operating

procedures. An effective ILSM program includes a champion

to lead this important aspect of a project, and should also

include a training program that communicates the importance

of the ILSM program to all stakeholders in the planning,

construction and operation of the affected facilities.

••• The Interim Life Safety Measure Compliance Checklist is a tool that can be used to assist you with monitoring and documentation of project ILSM performance.

Taking a fire alarm system out-of-serviceTaking a sprinkler system out-of-serviceDisconnecting alarm devices

MAINTENANCE AND TESTING

INTERIM LIFE SAFETY MEASURE

Hazardous areas not properly protected

CODE DEFICIENCIES

CONSTRUCTION

Blocking off an approved exitRerouting of traffic to emergency roomMajor renovation of an occupied floorReplacing fire alarm system (out of service)Installing sprinkler system ( out of service)Significantly modifying smoke or fire barrier wallsAdding an addition to an existing structure

Excessive travel distance to an approved exitLack of two remote exitsNonconforming building construction typeImproperly protected vertical openingsLarge penetrations in fire barriersCorridor walls do not extend to the structure

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It’s more than just

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infection control considerations

Hospitals started paying attention to infection control in the

late 1880s, when mounting evidence showed unsanitary

conditions were hurting patients. While hygiene in hospitals

has been a great concern ever since, and significant

improvements have been made, an estimated 1 in 20 patients

still pick up infections they didn’t have when they first arrived

at a hospital. Add construction activity to the mix, and the

challenge to keep patients free of infection becomes even more

challenging. The most common microbes associated with

construction activity are Aspergillus, a fungus found in dust,

soil, moisture and mold; and Legionella, a bacterium found in

water. These can cause serious infections if measures are not

taken to mitigate this risk.

The Facilities Guidelines Institute recognized the importance

of this issue by adding an entire section to the 2010 Guidelines

for Design and Construction of Health Care Facilities dedicated

to the infection control risk assessment (ICRA). ICRA is a

multidisciplinary, documented assessment process intended to

proactively identify and mitigate risks from infection that could

occur during construction activities.

This process identifies and takes into account the patient

population at risk, the nature and scope of the project and the

functional program of the healthcare facility. ICRA determines

the potential risk of transmission of various air and waterborne

biological contaminants in the facility. Plans for preventive

measures, barriers, monitoring and cleaning need to be

implemented to minimize exposure.

Typical issues covered in ICRA include: (1) mitigation of dust

and debris from construction activity with sealed plastic and

drywall barriers, (2) maintenance of negative air pressure

within construction areas to prevent the migration of dust,

(3) isolation of HVAC systems to prevent contamination into

patient areas, (4) controlled transportation and disposal of

construction debris in covered carts, away from air intakes,

(5) isolation, flushing and decontamination of water systems

affected by construction, (6) regular cleaning of the worksite

and (7) testing and inspection of construction areas and related

systems to confirm safety for patient use, as well as many more

issues that may be specific to the unique aspects of any given

renovation program.

The most effective ICRA process is collaborative, including all

project stakeholders. The process should start well before

construction begins, and only conclude when the environmental

conditions have been confirmed to be safe in the newly

renovated areas by the standards set forth in the ICRA process.

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A safe environment

higher HCAHPS scores

HAPPY PATIENTS

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patient safety considerations

Just because you are not starting with a “clean slate” as you would when designing

a new patient tower, it is important to remain open-minded when planning a patient

floor renovation. Yes, there may be budget constraints, but don’t allow the existing

room layout to limit opportunities to increase patient safety and satisfaction.

Studies show that patients recover more quickly if they are encouraged to restore

their independence. Many older patient rooms were designed when patients were

encouraged to remain and recuperate in bed with little or no consideration to support

mobility. Patient rooms today are designed to promote healing and feature elements

to support restoring a patient’s ability to move about and regain their independence

and confidence.

Typically, hospital falls occur most often when patients attempt to get to the

bathroom. So in your renovation, if your headwall is not located on the wall closest

to the bathroom, consider relocating the headwall or the bathroom so the patient

doesn’t have to cross an open floor. Consider installing multiple lighting options,

including embedded floor lights leading to the bathroom, controlled by the patient’s

pillow switch to reduce falls and injuries due to room darkness. Another key patient

satisfier is having the ability to control the window shades.

One of the most common complaints in any hospital is noise. When renovating a

patient floor, consider noise reducing design elements such as rubber floors, thicker

carpets and acoustic panels. This would also be an excellent time to review your

equipment and alarm system configuration. Don’t just accept default alarm settings,

adjust them to specific patient acuity.

All of these design considerations and interior elements contribute to not only a safer,

but more pleasant hospital stay, which will translate into higher HCAHPS scores.

••• The sheer number of alarms that sound throughout the day can cause serious consequences from alarm fatigue for clinicians.

© Scott Pease

© Scott Pease

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engineering considerations

Often, business leaders refer to facilities as the “bricks and mortar” part of their

operation. When it comes to healthcare facilities, it is not uncommon to invest more

in “air and water” than “bricks and mortar.” Heating, Ventilating, Air Conditioning,

Plumbing and Electrical Engineering systems can often account for well more than

50% of the cost of any given renovation project.

Of all these top ten considerations, this is probably the most challenging to address

without considerable upfront investment to determine the specific condition of the

facilities in question. Hidden above the ceiling and behind the walls are thousands

of linear feet of piping, conduit, ductwork and equipment that are in some respects

similar to the vital organs within the human body. We cannot see them, but we know

they are important.

A comprehensive facility condition assessment can go a long way towards shedding

some light on what otherwise could remain a mystery until uncovered during

the construction phase of a renovation project – when surprises are expensive.

Renovation projects can often provide the ideal opportunity to correct facility

deficiencies, and under the right circumstances can actually pay for themselves

through improved operational costs that will be realized over the life of the facility.

For example, an outdated/inefficient HVAC system could be replaced with a state-

of-the art system (with energy efficient controls). A life cycle analysis would

demonstrate how many years of energy savings it would take to essentially pay for

the one time capital improvement costs. Furthermore, a patient bed tower renovation

project provides an ideal environment to effectively replace key systems, while the

controls are in place to accommodate the primary construction activities underway.

© Jeffrey Totaro

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ARE NOT THE ANSWER

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IT infrastructure considerations

In the wake of healthcare reform, with its emphasis on EMRs and Meaningful Use

implementation, IT Infrastructure has become be a larger line item of hospital capital

budgets and will remain so for the next 10 years as CMS reimbursement encourages

ACOs and bundled payments. Clinical Integration Networks (or CINs) will be required

to allow caregivers across the spectrum of care access to the data of patients that will

live longer and may require a higher level of care.

Because medical technology is one of the fastest advancing industries in the world,

your architect should assess the scope and magnitude of your renovation project

and its impact. If it is a simple upgrade, or an individual floor renovation, the project

can be evaluated individually, but if you are planning an entire tower upgrade, you

may consider a more comprehensive approach that relocates “soft functions” into

the oldest, tightest areas, in order to open up adequate space to accommodate the IT

infrastructure necessary to support evolving technology. Initial costs may be higher,

but you will be well positioned for future advancements.

When converting older, smaller units, often there is not enough square footage

available on the patient floor to “fit everything in.” As clinical activities and

communication move to dashboards, coupled with the rise of hand-held BYOD (Bring

Your Own Device) which largely applies to physicians for now but will undoubtedly

increase in the future, renovations need to incorporate alternate access modes

complementary to traditional PC nodes (i.e. secure WiFi, wall-mounted touch screens,

large panel displays with updating/scrolling info) and provide space for the IT

infrastructure required to support it. As EMR access becomes the hub of all activity

on the floor, providing frequent, comfortable, convenient and reasonably private

access points is critically important.

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ACCESSibility

is more than just clearances

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© Scott Pease

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accessibility considerations

Perhaps one of the most vexing elements of upgrading a

patient tower is addressing accessibility issues. This is due

in large part to the many different regulations and oversight

organizations. The original American with Disabilities

Act (ADA) and the revised Act effective March 15, 2011,

guarantees the civil rights of all disabled people, and is not

just limited to physical disabilities. In the summer of 2012,

the Department of Justice and Attorney General announced

a new, joint-enforcement program called the “Barrier-Free

Health Care Initiative” with the goal of ensuring that persons

with disabilities have access to medical information as well as

physical access to medical buildings.

The initiative addresses many aspects of healthcare

environments and services, such as facilities, diagnostic

equipment, websites, parking, transportation, information

in alternative formats, videophones and sign language

interpreters. Another caveat: be aware that the ADA standards

are enforced as civil rights violations and are separate from

building code violations.

This “mish mosh” of regulations impact patient tower

renovations on multiple levels. The best advice: anticipate

the needs of disabled patients during their entire hospital

stay while in the planning phase. Try this tip: during design

try to visualize the entire path of travel from the drop-off point

to the patient’s destination. Referred to as the “ADA Path of

Travel” requirement, this technique will help you incorporate all

codes: parking, drop-off, entrances, protruding objects along

corridors, toilet rooms, signage and alarms. Note: ADA codes

apply to most employee as well as public areas.

Note, meeting minimum ADA standards leaves no place for

dispensers, trash receptacles and supply tables without

compromising the clear maneuvering space required for

caregivers to assist a patient. Also, meeting ADA minimum

standards does not address bariatric design. With the

increased obesity in the general population, patients, staff and

visitors require larger door widths, as well as stronger toilets,

grab bars and chairs.

A valuable lesson learned from experience: while architects

design correctly and meet all code requirements, make

sure your contractor follows the design. Often contractors

construct to the standards they have used for generations, and

toilets are installed too far from the wall, grab bars are placed in

the wrong location and sink details are not followed resulting in

constricted knee space underneath. These construction errors

create functional difficulties and code deficiencies that can be

very expensive to correct.

ACCESSibility

is more than just clearances

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Can you make your father’s

OLDSMOBILE run like a

PRIUS?

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sustainability considerations

As citizens of the planet, this data alone should encourage all hospitals to investigate

all sustainable options possible in the design and construction of their facilities.

While achieving Silver or Gold LEED Certification on your patient tower renovation

project may set the sustainability bar a bit too high, there are many incentives and

options for pursuing environmentally-friendly design choices that could achieve LEED

certification.

First, investigate all opportunities to recycle your construction waste. There are

many organizations who will literally take the waste off your hands. The secret: early

coordination meetings with the entire team (owner, architect, contractor) to identify

materials that can be up-cycled to a non-profit organization and select items to be

recycled, all with the goal of reducing the amount of waste being sent to the landfill.

Second, identify design and engineering options that reduce electricity and water use.

For example, in a multi-floor renovation, sizing air-handling units to serve additional

floors, even those not being renovated, could increase efficiency, lower heating and

cooling costs as well as improve the indoor air quality.

Lastly, focus on selecting sustainable project materials that support high indoor

environmental quality (IEQ). On a recent two-floor hospital renovation project in New

Jersey, 13 of 35 LEED points were in the IEQ category. Ask your architect to research

materials such as doors and carpets that can be purchased within 100 miles of your

hospital - it will result in additional LEED points.

A combination of these strategies could contribute to LEED certification. Several of

these green building strategies may cost more initially, but if healthcare executives

can get over the short-term fiscal hurdle, the dividends for both the hospital and

environment could be huge later on.

The typical hospital uses as much energy in a year as 3,500 households.

This energy consumption has substantial carbon dioxide and operational

cost impacts, equal to the emissions of 5,950 cars on the road each year,

at an average annual cost up to $4,000,000.

••• Source: US EPA Greenhouse Gas Equivalences Calculator.

Electricity Rate $.11/kwh (US National Average 2012)

The typical hospital uses as much water in a year as 350 households

of 3 people. This water demand has substantial environmental and

operational cost impacts, equal to filling a bathtub 1,000,000 each year

at an average annual cost up to $800,000.

••• Source: Water supply and sewer rates, $7 and $9 /100 gallons

(2012)

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“We’re all in this TOGETHER.”

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© Blake Marvin

patient/family-involved care considerations

The concept of patient-centered and family-involved care is self-evident, and simply

put, the way that healthcare should be delivered. However, many of the hospitals

considering renovating their patient floors were not designed for the healing of patients

and comfort of family. Consider, for example, how the focus of many older hospital

rooms is the somewhat frightening medical equipment, while the halls throughout are

painted in practical, hospital green with noisy, but easy-to-clean linoleum floors.

As you consider renovating an outdated patient tower, you will have an opportunity to

re-invent the patient experience. Remember to provide spaces that offer a range or

hierarchy of interaction for patients, staff and families that range from interactive to

private. Examples include:

• A lobby or cafeteria (public)

• A chapel or reference library (semi-public)

• A family lounge (semi-private)

• A patient room or consultation area (private)

Again, use visualization techniques or process mapping to document the patient and

family experience from admission through checkout. Your goal, and what you should

ask your architect to do, is reduce or eliminate all barriers between patients and

clinicians so the physical environment supports the care giving process, empathy

and education about their condition. In a renovation, you have the opportunity to

reconfigure the patient room to allow family members — historically viewed as

operationally inconvenient — to become true partners in their loved one’s care.

Evidence points to the real benefits of healthcare facilities designed around patient,

family and staff needs and preferences. These benefits not only improve patient

outcomes and increase staff effectiveness and morale, they also help administrators

meet key safety goals, reduce costs and increase market share.

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© Scott Pease

© Jeffrey Totaro

© Scott Pease

© Kevin G Reeves

CHECKPOINT

Discovery

Analysis

We believe healthcare design projects must focus on providing high value solutions that support best practices, foster collaboration, promote outstanding patient experiences and anticipate future flexibility. Working together with you, we map an optimal future work flow and patient experience through process mapping, operational planning, virtual mock-ups and simulation modeling as we work to develop a comprehensive project that supports your mission of caring for your community.

OUR APPROACH

PROCESS-LED LEAN DESIGN

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CHECKPOINT CHECKPOINT CHECKPOINT

AnalysisCreation

Solution

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