Top Ten Considerations When Renovating Your Patient Tower by Array Architects

TOP TEN CONSIDERATIONS WHEN RENOVATING YOUR

patient TOWER

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.

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

••• Misalignment of the care

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

model and the physical layout

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

can mean a design that doesn’t support the way staff work and could even inhibit them.

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.

logistical considerations It is tempting for hospital facilities to simply change the door signage of a semiprivate 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.

••• Vertical Stacked Phasing

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.

••• Horizontal Stacked Phasing

life safety considerations

Providing a safe environment for patients, staff, family and

These features are often compromised during construction

visitors is clearly the utmost priority – and responsibility - of

within an operating facility, so the Joint Commission on

any healthcare organization. Turning an operating nursing

Accreditation of Healthcare Organizations (JCAHO) developed

unit into a temporary construction site creates numerous

Interim Life Safety Measures to protect the safety and health

environmental challenges that can only be addressed with

of patients by compensating for any hazards caused by

proper planning and execution of a well-conceived plan that

construction activity.

incorporates proven interim life safety measures (ILSM).

There are main steps in the planning and implementation of

A properly planned and executed ILSM will result in zero

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

disruptions to patient care and hospital operations. In basic

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

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

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

designed to protect the safety of patients, visitors and staff

procedures. An effective ILSM program includes a champion

who work in the hospital facilities, including specific safety

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

features such as egress corridors, exit signs, fire protection

include a training program that communicates the importance

systems (smoke detectors, sprinklers, fire extinguishers and

of the ILSM program to all stakeholders in the planning,

fire alarm systems), smoke barriers, emergency evacuation

construction and operation of the affected facilities.

plans and many other items.

Patient room door latching problem Lacking a code complying smoke barrier Fire exit stairs discharge improperly Excessive travel distance to an approved exit CODE DEFICIENCIES

Lack of two remote exits Nonconforming building construction type Improperly protected vertical openings Large penetrations in fire barriers Corridor walls do not extend to the structure Hazardous areas not properly protected Blocking off an approved exit Rerouting of traffic to emergency room

Post alternative exit signage

Initiate fire watch

Notify fire department

Additional staff training on building deficiencies

Staff awareness training

Inspect and test temporary systems monthly

Additional fire drill per shift per quarter

Additional training on the use of firefighting equipment

Enforce storage, housekeeping and debris removal practices

Increased survellance

Temporary construction partitions

Additional firefighting equipment

Temporary fire alarm and detection system

Inspect exists daily

INTERIM LIFE SAFETY MEASURE

EXISTING LIFE SAFETY CODE DEFICIENCIES OR CONDITIONS AS A RESULT OF CONSTRUCTION

••• 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.

Major renovation of an occupied floor CONSTRUCTION Replacing fire alarm system (out of service) Installing sprinkler system ( out of service) Significantly modifying smoke or fire barrier walls Adding an addition to an existing structure Taking a fire alarm system out-of-service MAINTENANCE AND TESTING Taking a sprinkler system out-of-service Disconnecting alarm devices

It’s more than just

WASHING

your hands.

infection control considerations

Hospitals started paying attention to infection control in the

This process identifies and takes into account the patient

late 1880s, when mounting evidence showed unsanitary

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

conditions were hurting patients. While hygiene in hospitals

functional program of the healthcare facility. ICRA determines

has been a great concern ever since, and significant

the potential risk of transmission of various air and waterborne

improvements have been made, an estimated 1 in 20 patients

biological contaminants in the facility. Plans for preventive

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

measures, barriers, monitoring and cleaning need to be

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

implemented to minimize exposure.

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.

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

The Facilities Guidelines Institute recognized the importance

construction debris in covered carts, away from air intakes,

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

(5) isolation, flushing and decontamination of water systems

for Design and Construction of Health Care Facilities dedicated

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

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

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

multidisciplinary, documented assessment process intended to

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

proactively identify and mitigate risks from infection that could

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

occur during construction activities.

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.

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,

••• The sheer number of alarms that sound throughout the day can

adjust them to specific patient acuity.

cause serious consequences from

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

alarm fatigue for clinicians.

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

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 stateof-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.

ARE NOT THE ANSWER

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.

accessibility considerations

Perhaps one of the most vexing elements of upgrading a

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

patient tower is addressing accessibility issues. This is due

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

in large part to the many different regulations and oversight

apply to most employee as well as public areas.

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

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.

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 Travel” requirement, this technique will help you incorporate all

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

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.

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)

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

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.

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.

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

(2012)

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.

“We’re all in this TOGETHER.”

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) © Scott Pease

• 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.

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.

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