The many benefits of caring for patients within a private room have been proven for decades. Often, the benefits may be clear, but the perceived cost of providing more private patient rooms has prevented the wholesale adoption of this basic principle. Building new bed towers has been an option for systems that could afford to build new facilities. 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 trend toward 100 percent private rooms.
At face value, 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. As this trend continues, just remove the second bed from the semi-private room and – voilà – problem solved!
Not so fast
There are a variety of considerations that need to be thoughtfully addressed when converting semi-private rooms to private. 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 10 list of considerations to help healthcare organizations develop effective plans when considering renovating/converting existing semi-private bed units into private bed units.
1. Finding the balance between Lean and mean
Conventional wisdom historically has supported the notion that a typical medical/surgical unit operates most efficiently within a range of 24-36 patient beds per unit. Depending upon the size of the existing unit, it can be challenging to achieve these ideal ratios when converting to an all private room model.
Implementing Lean principles during design helps 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. 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.
2. Logistical considerations
It is tempting for hospital facilities to simply change the name on the door of a semi-private room, paint the walls and call it a day. But experience has demonstrated this is not a long-term solution due to the impact on the operational model when converting to a private bed room 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.
3. Life safety considerations
Providing a safe environment is clearly the utmost priority. Turning an operating nursing unit into a temporary construction site creates numerous environmental challenges that can only be addressed with proper planning and the execution of a well-conceived plan that incorporates proven interim life safety measures.
A properly planned and executed ILSM will result in zero disruptions to patient care and hospital operations. There are main steps in the planning and implementation of interim life safety measures: (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.
4. More than just hand-washing
The Facilities Guidelines Institute recognized the importance of infection control during construction by adding an entire section to the 2010 Guidelines for Design and Construction of Health Care Facilities dedicated to the infection control risk assessment. An ICRA is intended to proactively identify and mitigate risks from infection that could occur during construction activities.
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.
5. Safe environment + happy patients = higher HCAPHS scores
Typically, hospital falls occur most often when patients attempt to get to the bathroom. If a headwall is not located on the wall closest to the bathroom, consider relocating the headwall or the bathroom so the patient never has 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.
All of these design considerations and interior elements contribute to not only a safer, but more pleasant hospital stay, which will translate into higher HCAPHS scores.
6. Engineering considerations
Heating, ventilating, air conditioning, plumbing and electrical engineering systems can often account for well more than 50 percent of the cost of any given renovation project. And engineering is probably the most challenging to address without considerable upfront investment to determine the specific condition of the facilities in question. A comprehensive facility condition assessment can go a long way toward 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.
7. Accommodating technology
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. 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, renovations need to incorporate alternate access modes complementary to traditional PC nodes (e.g., secure Wi-Fi, 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.
8. Accessibility is more than handicapped toilets
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. It’s best to anticipate the needs of disabled patients for their entire hospital stay during planning phase. Try this tip: during design, 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 to incorporate all codes for 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.
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.
9. Making your father’s Oldsmobile run like a Prius
There are many incentives and options for pursuing environmentally friendly design choices that could achieve LEED certification.
First, investigate all opportunities to recycle construction waste. There are many organizations who will literally take the waste off your hands. Identify materials that can be up-cycled to a nonprofit organization and select items to be recycled during early coordination meetings.
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 materials that support high indoor environmental quality. On a recent two-floor hospital renovation project, 13 of 35 LEED points were in the IEQ category. Also, research materials such as doors and carpets that can be purchased within 100 miles of the hospital; it will result in additional LEED points.
10. Creating new spaces to support family involvement
Many hospitals have been considering renovating — or have renovated —patient floors that 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 a practical, hospital green with noisy, but easy-to-clean linoleum floors.
Renovation of an outdated patient tower provides 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:
- Lobby or cafeteria (public)
- Chapel or reference library (semi-public)
- Family lounge (semi-private)
- Patient room or consultation area (private)
For additional information and case studies highlighting specific solutions to patient tower renovation challenges, visit http://www.array-architects.com/design-books/top-ten-considerations-when-renovating-your-patient-tower/.
Images by Jeff Totaro.
