The convergence of facility planning and IT planning in a health care organization
“Form follows function” is one of the most basic architectural tenets—and within the health care industry, a paradigm shift has occurred in both its form and function components.
The shift in function has been rooted in the adoption of patient privacy measures and advanced clinical informatics technologies into substantially every clinical process. The form shift has been driven by these changes and a recent explosion of patient-centric hospital construction. These drivers have fundamentally changed the dynamics of space use and, importantly, have required a much earlier involvement of information technology in facility design than ever before.
This new paradigm has caused more than one health care organization to rethink the way their facilities and IT departments collaborate. This paper, then, will review the “traditional” facility/IT organizational engagement, elaborate on the paradigm shift drivers, describe the best practices used within Spectrum Health to respond to the shift, and finally, discuss the challenges faced in implementing this model.
Spectrum Health Background
System Mission, Values, and Footprint
Spectrum Health is a West Michigan-based integrated health care system dedicated to improving the health of the communities served. The vision is to be the nation’s highest quality and most successful health care enterprise by 2010. Our behaviors are modeled on the core values of compassion, excellence, innovation, integrity, respect, and teamwork.
Spectrum Health, a not-for-profit organization, is the largest employer in West Michigan with 14,000 staff, 1,500 physicians, and 2,000 volunteers. It is a $2+ billion enterprise with two main businesses: Priority Health, a health insurance provider; and the Spectrum Health delivery system, which offers the full continuum of inpatient, ambulatory, and continuing care services. It is one of 41 health care systems to have attained an Aa3 rating from Moody’s Investors Service.
The focus of this paper will be on Spectrum Health’s delivery system, which has seven hospitals and 140 ambulatory/primary care offices. It is the largest provider of integrated, post-acute and long-term care in West Michigan and the second-largest provider of adult and pediatric indigent care in Michigan. It had net revenues of $1.3 billion in 2007.
Specialty services include cardiovascular, orthopedics, oncology, pediatrics, neonatal, neurology, bariatrics, digestive diseases, occupational health and rehabilitation, long-term acute care, home care, and hospice services. With 1,860 licensed beds, the hospitals handled some 200,000 emergency department visits and 63,000 acute care admissions in 2007. The long-term care, home care, and hospice programs served more than 1,200 patients per day.
Since 2004, Spectrum Health has made a significant commitment to facility renovations and construction. Major projects have included the Fred and Lena Meijer Heart Center (2004), the West Pavilion Ambulatory Care Center (2006) ,the Lemmen-Holton Cancer Pavilion (2008), the Blodgett Hospital Patient Wing (to open in 2010), the Helen DeVos Children’s Hospital (to open in 2011), and a Consolidated Lab (to open in 2011). In addition, Spectrum Health annually spends around $25 million on facility projects such as patient wing renovations, new major medical equipment installations, and infrastructure upgrades.
The Traditional Facility Planning Model
The Plan-Design-Build Facility model
The seven-phase traditional construction development model is shown in Figure 1. Prior to 2000, Spectrum Health directly managed and performed the work in all phases except construction, and managed—but outsourced—the actual construction work.
Figure 1: Construction development model
Business vision identifies the construction drivers and business case. It includes business analyses like market segmentation or growth, and a pro-forma that identifies the return on investment. It is at this time when the first real customer expectations of construction are set.
Programming is the preparation for design. Space use, square footages, and initial budgets are based on the strategic business case and historical data for the type of structure being considered. The key deliverables of this phase include a space program and high-level budget/timeline estimates. Endemic in this phase is the use of work-flow process planning to describe departmental process relationships and required physical adjacencies.
Schematic design signals the beginning of design and brings form to the building itself. It further defines departmental spaces, common areas, and building support spaces. Key deliverables include room data sheets, a schematic floor plan, and more detailed budget/timeline estimates.
Design development begins to finalize all of the major details required for construction. This includes, but is not limited to, building exteriors and interiors, furniture and fixtures, infrastructural elements, and equipment.
Construction documents use the design development documents to produce contract drawings and specifications. These documents define the requirements of construction and are used to award construction bids.
The construction phase is where the actual construction work is performed. The quality, timeliness and cost-effectiveness of the work is constantly monitored and managed during this phase by teams and committees comprised of the architect, construction manager, and owner representatives.
The occupancy phase begins after construction is substantially complete and a Certificate of Occupancy is granted. This phase includes the completion of miscellaneous “punch list” items, owner “fit-out”, and the logistics of occupying the new work space.
Information Technology’s Place within that Traditional Model
Architectural and construction management firms have traditionally entrenched IT design considerations as a subset of electrical engineering. IT’s direct involvement typically begins in the design development phase, well after process and budget expectations have been set. At an April 2008 webinar hosted by C.H.I.M.E. on this topic, an informal poll of attendees showed that only 3 of 20 respondents regularly begin IT’s involvement in the programming phase and 4 in schematic design, while13 did not begin until design development or later. As recent as this year, three different consulting architecture firms planning new Spectrum Health construction were using standardized questionnaires that placed technology as a two-item subsection under their electrical section.
Viewed historically, this insertion point was pragmatically acceptable as the IT effect on construction was, in fact, somewhat limited. Hospitals had, until this last decade, depended on paper-based clinical workflows and utilized relatively small numbers of computer terminals, printers, or telephones. Medical equipment like physiological monitors and diagnostic imaging machines also required little or no IT involvement.
The Paradigm Shift Drivers
By the late 1990s, however, a number of forces began to converge within health care that would greatly impact this model. They included the enactment of patient privacy regulations, the adoption of advanced clinical informatics technologies, and a movement to build more patient-centric facilities.
Patient Privacy (HIPAA-driven Information Sharing)
The Office for Civil Rights (OCR) within Health and Human Services (HHS) issued the Standards of Individually Identifiable Health Information (the Privacy Rule) in December of 2000, pursuant to the directives in Title II of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Title II’s final version, adopted in August of 2002, stated the following:
The major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well being. (OCR, 2003, p. 1)
The impact of this rule was felt not only in to whom patient information was shared but also where it was shared as well. “Protected” conversations between anyone discussing patient information became restricted in public places like hallways, elevators, cafeterias, waiting rooms, and open registration areas. Restrictions even applied in patient holding areas, exam rooms, and semi-private patient rooms. Practically, this meant that the uncomfortable but common practice of discussing patient information in shared spaces was not just troubling for all involved, but was now illegal.
Advanced Technology Implementations
Electronic Health Record.
Historically, the health care industry has lagged behind other industries in their use of electronic records. Central to that were clinical care models necessarily based upon paper charts. These care models began to change in the early 2000s as the industry was faced with a widening gap in patient volumes/caregiver ratios, patients becoming more actively involved in their own plans of care, increasing referrals to specialists, and increased levels of diagnostic testing.
A major response to these changing models was the adoption of electronic health records (EHRs). Only 12% of hospitals surveyed in the 2002 HIMSS Annual Leadership Survey had fully implemented an EHR. That percentage had almost tripled to 32% by 2007. By the same token, 29% of the respondents in 2002 had no plans to implement an EHR and in 2007 that percentage had dropped to a mere 8%. Furthermore, private physician practices of less than 10 physicians (60% of all practices) had an average adoption rate of 18% in 2003, 24% in 2006, and an estimated rate of 40% by 2010. The lending weight to this response was the 2004 issuance of a presidential executive order “...establishing the Office of the National Coordinator for Health Information Technology (ONCHIT) with the mission of implementing electronic health records (EHRs), nationwide, within 10 years” (Ford, Menachim, & Phillips, 2005, p. 1).
Point of Care Computing.
Leveraging wireless and high-speed data networks, a second major response was point-of-care computing. Whereas patient data was previously “sequestered” in medical records departments, nursing stations, and operating suites, technology designs began centering on how to best bring the EHR into exam rooms, patient rooms, and even the patient’s home. This seriousness of this response was made clear as 84% of hospital respondents in the 2006 HIMMS Leader Survey noted were currently using wireless networks, 95% had implemented a high speed network, 77% had placed workstations-on-wheels in their environments, and 62% had concentrated some efforts on hand-held PDA’s.
In Spectrum Health’s experience, point-of-care computing has been an augmentation, not a replacement, of fixed devices. It has not materially lessened the use of devices at nurse stations or physician work areas; rather it opened the door to implementing emerging technologies like Clinical Nursing/Physician Documentation and Barcode Medication Administration (BCMA).
EMRs and computerized practitioner order entry (CPOE) were the IT applications that respondents cited most frequently as being the healthcare application areas they considered to be important to their organization in the next two years... Nearly three-quarters of respondents indicated that bar coding technology was the technology that respondents were most likely to report that they would use in the next two years. (Healthcare Information and Management Systems Society [HIMMS], 2007, p. 8)
These technological advances have had enormous facility implications as they became integral parts of the entire patient encounter, resulting in a significant shift in the way healthcare space usage had to be viewed and designed.
Hospital Construction Boom
The “form” shift has been evident in a hospital construction boom that is meant to replace obsolete facilities that were never built to address the new privacy concerns, advancing technologies, and changing patient demographics.
... many of today’s hospital are ill-equipped to accommodate emerging new technologies and to treat a higher-acuity patient population. With Hill-Burton era facilities aging beyond salvage, demand outstripping current capacity, and competitive pressures raising the bar for technology and amenities...record numbers of hospitals and health systems are breaking ground on ambitious building projects. (The Advisory Board Company, 2007, p. 6)
According to the Health Care Advisory Board, annual spending on hospital construction rose from $2 billion in 1998 to $5 billion in 2005, an increase of 150%. At its core is a transition from semi-private to private patient rooms. “...(T)he overwhelming majority of new hospital bed tower projects now underway are designed with private rooms” (Health Care Advisory Board, 2007, p. 28). It is a movement that addresses a number of important considerations that include patient safety, patient comfort and privacy, and higher levels of family involvement in bedside patient care. Private room construction has become so prevalent that the American Institute of Architects changed its hospital construction guidelines on patient rooms in 2006. “In new construction the maximum number of beds per room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement” (American Institute of Architects, 2006, pp. 2.1-18.104.22.168).
A corollary to the shift in patient room design was the ergonomic and “footprint” requirements of a burgeoning use of devices within nursing units, procedure areas, and physician practices, and as such, the design dynamics of space usage and layout had fundamentally changed.
The Spectrum Health Model
Spectrum Health seriously began feeling the stress of these paradigm shifts on its construction model as early as 2004. Prior to 2005, Spectrum Health had few IT resources assigned as connection points between facilities and IT. With a quickly expanding construction portfolio, those resources spent the majority of their time reacting to construction requests for immediate action, leaving little time to consider important technological complexities. Moreover, there were gaps in considering the true IT costs as a portion of the capital construction project budget. IT budgeting was based on a limited and outdated knowledge of the hardware and software that was used throughout the system.
Recognizing these gaps, Spectrum Health embarked on both a facilities process improvement program and a grass-roots effort in 2005. The process improvement (PI) program was focused on core process redesign and the grass roots effort was a collaboration to specifically build a more effective partnership between facilities and IT.
The Process Improvement (PI)
The 2005 PI effort led Spectrum Health to implement a construction model that split a project into two management phases.
The first phase involved the creation of a facilities planning and development department (FP&D) that focused on taking a construction project from the initial point of conception through the end of the schematic design phase— with FP&D ensuring that appropriate customer PI sessions were held to better define effective space use. FP&D then created an Integrated Facility Planning Package that documented the project’s scope, proposed schematic floor plan, room data sheets, IT considerations, infection control assessment, preliminary schedule, and high-level budget. That package was submitted for consideration into the capital planning process and, once approved, the project was handed-off to the design and construction services department (D&CS), with the FP&D planner remaining engaged to provide continuity.
The second phase, led by D&CS, started with a review of the integrated package and a determination of the final design and construction method to be employed. Typically, a consulting architect was hired to produce the design and construction packages needed through the end of the construction document phase. During this time, both FP&D and D&CS monitored the continuing development of the project to ensure compliance with the budget and the scope. Once the construction documents were complete and approved, the D&CS project manager proceeded to bid, permit, and construct the project. As the construction phase neared completion, a D&CS-defined role of logistics coordinator began to play a critically active role in the occupancy phase.
The Grass Roots Effort
At the same time, facilities and IT used a grass roots approach to solve the gap in IT engagement. The core to this was the creation of a joint facilities planning and IT team that inserted IT as far forward as the visioning phase. Four process keys to this insertion were to:
- Establish a weekly planning overview meeting to provide a forum for discussing workload and for escalating individual project issues.
- Directly involve IT in FP&D’s programming and PI sessions so that IT requirements could be identified and included within the scope of the project.
- Mimic the FP&D hand-off to D&CS within the IT process. The IT planner would either continue through the project as the IT coordinator or would hand-off the project to an assigned IT resource and would stay engaged in a consulting role.
- Develop a standard “toolset” and expectations for its consistent use.
This process change required a change in behaviors. That change was less the development of new behaviors as it was the extension of current accepted behaviors into a new team. In essence, the team developed along the classic lines of Forming, Storming, Norming, and Performing as described by Dr. Bruce Tuckman (1965). The keys to that development included:
- Establishing a common vision and building trust in that vision,
- Agreeing on roles within a multi-disciplinary team and building trust in each others’ expertise,
- Allowing a “grass roots” accountability in the model to develop,
- Providing decision-making authority at the team level, and
- Supporting the model by department and executive management.
A concurrent development occurred in the use of a standard tool set. The key tools included:
- The integration of the current, silo-ed planning documents into a package that “grew” as a project moved through its phases. This was built more by enhancing existing planning documents than by creating new documents.
- The use of a portfolio management application that provided an organization-wide awareness of the facility department’s “book of work.” This allowed cross-project impacts to be more fully considered as project scopes, schedules, and budgets were developed.
- The development of a high-level IT budget estimating tool. Historically, IT provided adequate cost estimates when given detailed usage information but struggled to provide credible estimates when provided only general square footage and usage criteria. In response, a tool was built to express IT cost as a range of cost per square-foot. A meaningful range was developed by analyzing construction projects over 5,000 square feet and taking care to understand which IT components were specifically included in the calculation. The inclusions initially chosen were network infrastructure equipment, low-voltage wiring, voice systems, and general-use computers. A variation in the range was built to accommodate the differing types of computing used within the defined space (e.g., clinical vs. non-clinical, departmental vs. public use). Added to this range were project-by-project estimates for items known to be excluded from the base calculation.
This toolset continues in use today, with its success being dependent on the continuous refining of the components included in the multiplier. This refinement is based upon prior project learnings and a growing “umbrella” of IT-supported components.
Exhibit 2 depicts the IT insertion into early planning, use of an integrated planning package, and required formal hand-offs.
Figure 2: Integrated facility planning package
The Model Benefits
The following benefits became quickly evident:
- A surge in customer confidence in the team’s ability to create a quality design as the team and their “downstream” resources began to feel a sense of engagement that was, heretofore, strikingly absent.
- The availability of credible, high-level IT estimates for use during the early planning phases—something the team could not find to exist within construction industry estimating tools.
- An improved ability to anticipate IT resource requirements far enough ahead of construction to ensure adherence to schedule. This enabled IT to proactively develop measures to mitigate long IT lead-time bottlenecks like infrastructure upgrades, new wide-area networks, or major application upgrades.
- A more complete audit profile for determining and trending project successes and for applying lessons leaned to future projects.
One early example of the model’s success was the construction of a 50,000 square foot ambulatory center that was to house 8 different Spectrum Health departments. With programming beginning in October of 2005, occupancy was targeted for December of 2006 – a 14 month window (a full 4 months sooner than normal for projects of that size). Invoking the new model, the project moved quickly and seamlessly through its phases to an on-time, on-budget occupancy that led to very high customer satisfaction levels.
The Model Evolutions
The facility/IT planning team soon recognized the value of extending the new “engagement” model to other teams. This led to the model’s evolution, as depicted in Exhibit 3.
The first evolution was the formal inclusion of other departments into the early planning phases. These departments included D&CS, facilities support services, environmental services, infection control, real estate management, marketing, logistics, and revenue management. The reasons for doing so were the same that drove the formation of the facility/IT planning team—and the same benefits were realized.
The second evolution of the model was in response to a significantly increased workload through 2007. The effectiveness of a single facility planning meeting began to suffer as the number of team members and topics to discuss grew to match that workload. As a result, the model was extended by dividing the one team into three, each focused around a set of defined locations.
Exhibit 3: Integrated facility planning package
Implementing this model was not without its challenges. As a common vision and trust in that vision was the catalyst behind the model’s inception, solving challenges became more a matter of “how” versus “if.” Some of the challenges faced included language, accountability versus ownership, the lack of industry benchmarks for the IT tool, and model extensibility.
One major obstacle to be hurdled was developing a common vocabulary. Ostensibly simple words had different meanings to the IT and facility staff. “Program,” for example, meant the design of a space to a facility planner, a set of projects to a project manager; and “workstation” meant the work surface, walls, and storage space to a facility planner and a computer terminal to an IT planner. It became evident that facility and IT collaborators need to continuously “check-in” with each other to ensure common understanding and agreement of their language.
Accountability vs. Ownership.
Experienced planners are prone to exhibiting a strong sense of ownership over the processes and projects in which they are involved. Developing a sense of team ownership and shared accountability was difficult at the outset but occurred as both the facility and IT planners collaborated to define specific team roles. A key to solving this was the IT planners’ acceptance that IT requirements and activities needed to exist contextually within the facility-based project, not the other way around.
Credibility of the IT Tool.
The continual evaluation of empirical historical data provided an acceptable level of credibility. However, the lack of industry benchmarks made it difficult to evaluate whether the ranges were within reasonable bounds and to plan improvements to those ranges if they were not. This inability may well lead, in the long-term, to tool inaccuracies and inefficiencies that will impact its credibility.
Team expansion itself caused some recycling of Tuckman’s development phases. Moreover, most of the new team members had learned their respective crafts under the traditional model. Consulting architects, in particular, needed to be introduced to the model as well. All of this resulted in a need for all team members to be specific and open about team expectations and the new model nuances—especially as workload pressures tended to siphon away time needed for model reinforcement.
This model has shown itself to be both scalable and extensible within Spectrum Health. It is used on all facilities-based projects, regardless of size. Most notably, its strength has been seen in major in-patient floor renovations, physician office construction, and in Spectrum Health campus expansions. The tools are used consistently and each tool has been adapted to match the model’s evolution. Team behavior has become consistent – even in the face of expanding teams, increased workloads, and tighter deadlines. Finally, it can be noted that the most common root cause for projects that have not met expectations can now be traced to a lack of adherence to the model.
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The authors also wish to recognize and thank the following people for their valuable advice and comments: Lou Chiraldo, University Hospitals, Division Information Officer; Mike Dobb, Spectrum Health, Technology Systems Architect; Terry Dudley, Consultant, Spectrum Health Enterprise Clinical Care; Paula MacKenzie, Spectrum Health, Director, Public Relations; Greg Petersen, Spectrum Health, Senior Budget and Scheduling Coordinator; and Ryan Terry, University Hospitals, Division Information Officer
©2008, James Toth
Originally published as a part of 2008 PMI Global Congress Proceedings – Denver, Colorado, USA
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