morris switzer e n v i r o n m e n t s f o r h e a l t h
Facility Design with the Patients at the Center
Christine A. Schon, MPA, FACMPE VP Community Group Practices
Dartmouth-Hitchcock
Jennifer R. Arbuckle, AIA, LEED AP Partner
MorrisSwitzer ~ Environments for Health
Learning Objectives:
• Demonstrate the benefits & efficiencies of modular planning in project size and layout
• Identify efficiencies in cost & operation
• Review benefits of multi-disciplinary approach to care & applications in the Medical Home Model
• Describe the process for engaging physicians and staff in changing culture.
A physician champion
Leadership was able to foster creativity in an entire organization and drive consensus.
A completely re-engineered approach
From the parking lot to the bathrooms, how can we make this the best possible process?
An unusual building
80 providers in one building yet…
A remarkable project
• There are no boundaries between practice types • Every exam room is identical
■ Collaborative Practice Models Drive Efficiencies in Facility Design: Planning, Operations, and Costs
■ Challenges, Issues, Changes
■ Lessons Learned: The Case Study
Overview
Collaborative Practice Models:
Planning
Operations
Costs
Healthcare Regulatory changes…
Legislative drivers
Reimbursement models
Demonstrated efficiency requirements
Drivers of Change
Consolidated Location
Greater efficiency and collegiality through consolidation of practices/buildings.
Medical Home Model
A primary care team, led by the physician, working collaboratively to address the acute, chronic and preventative needs of patients.
Multi-Disciplinary Practice
Patient and staff benefits of placing primary care and specialists into a single building.
A New Practice Model
The Practice Model
Key Elements
Teamwork
Care Coordination
Population Health Metrics
Data registry coordination
Electronic Health Record
NCQA Certification
Medical Home Model
The Practice Model
Multi-Disciplinary Approach
Key Elements
Patient-Centered Care
Standard approached crossing disciplines & specialties
Care Navigation
Examples:
•Abnormal Mammogram
•Colon Cancer
•Hypertension
•Falls in the elderly
The Iterative Process
Steering Team Makeup
User Group Meetings
From Individual Needs to Departmental Needs to Collaborative Needs
The Practice Model
• Reflect our Mission and Vision?
• Enhance the true benefit of a collaborative group practice?
• Reflect our commitment to patient centered care?
• Promote “green principles”?
• Enhance the concept of a “Medical Home”?
Questions Explored during design process
How will our new facility…
The Practice Model
concepts
simple clean healing
organic natural timeless
connection to site
connection to community
Two Focus Groups DH patients non-DH patients the project Tools of Communication the blog
• Reflect our Mission and Vision?
• Enhance the true benefit of a collaborative group practice?
• Reflect our commitment to patient centered care?
• Promote “green principles”?
• Enhance the concept of a “Medical Home”?
Questions Explored on the Blog
How will our new facility…
No. Unit Area Net SF Notes Space
Exam Room 6 130 780 Large Treatment Room 1 150 150 MD Office 3 150 450 Office Manager 1 100 100 Business Office 2 80 160 2 workstations Nurse Work Area 1 150 150 Medical Records 1 150 150 Reception/Scheduling 2 60 120 2 stations Staff Break Room 1 150 150 Supplies/Storage 1 60 60 Waiting Area 10 20 200 10-12 people Toilet Rooms 3 50 150 2 patient/1 staff Housekeeping Coset 1 60 60 Data Closet 1 60 60
Sub-Total (DNSF) 2,740DNSF 1.4 Grossing Factor Total (DGSF) 3,836DGSF
Traditional MOB Functional Space Programming 3-Provider Suite
No. Unit Area Net SF Notes Space
Exam Room 10 110 1100 Large Exam Room 2 130 260 Treatment Room 1 150 150 Phlebotomy Station 1 120 120 1 draw station MD/Pract Offices 6 120 720 Offices 2 120 240 Prac Mgr, Billing Nurse Work Areas 6 60 360 Decentralized Nurse Station 1 100 100 Central Vital Sign Stations 3 40 120 Toilet Rooms 6 50 300 4 patient/2 staff Clean Utility 1 80 80 Soiled Utility 1 80 80 Supply Storage 1 100 100 Reception/Scheduling 4 80 320 Private booths Admin Work Area 1 80 80 Copier, Printer, Sup Staff Break/Conference 10 20 200 10-12 people Waiting Area 15 20 300 15-20 people Housekeeping Closet 1 60 60 Data Closet 1 60 60 Med Records Storage 1 100 100 Sub-Total (DNSF) 4,850DNSF
1.4 Grossing Factor Total (DGSF) 6,790DGSF No.
Unit Area Net SF Notes Space
Exam Room 20 110 2200 Large Exam Room 2 130 260 Treatment Room 2 150 300 Phlebotomy Station 2 120 240 2 draw station MD/Pract Offices 12 120 1440 Offices 3 120 360 Prac Mgr, Billing Nurse Work Areas 12 60 720 Decentralized Nurse Station 2 100 200 Central Vital Sign Stations 6 40 240 Toilet Rooms 8 50 400 5 patient/3 staff Clean Utility 2 80 160 Soiled Utility 2 80 160 Supply Storage 2 100 200 Reception/Scheduling 8 80 640 Private booths Admin Work Area 1 150 150 Copier, Printer, Sup Staff Break/Conference 15 20 300 15-20 people Waiting Area 25 20 500 25-30 people Housekeeping Closet 1 80 80 Data Closet 1 80 80 Med Records Storage 1 200 200 Sub-Total (DNSF) 8,830DNSF
1.4 Grossing Factor Total (DGSF)12,362DGSF
6-Provider Suite 12-Provider Suite
Space Programs for Traditional Medical Suite design:
Traditional MOB Functional Space Programming New Area Notes Individual Practices
Family Practice 12,000 12 providers Internal Medicine 7,000 6 providers
Oncology 4,000 3 providers
OB/Gyn 4,000 3 providers
General Surgeons 12,000 9 providers Gastroenterologists 4,000 3 providers
Pediatrics 4,000 3 providers
Urologists 3,000 2 providers
Building Areas (general):
Vertical Circulation 600 2 Stairwells, 2 Elevators
Mechanical 400
Electrical 200
Maintenance Space 200
Sub-Total (DGSF) 51,400Departmental Gross Square Feet 1.20 Estimated DGSF to BGSF Total (BGSF) 61,680Building Gross Square Feet
TOTAL No. of Providers = 41 +/- 1,500 SF per provider
Functional Space Program for Traditional Building area:
Traditional MOB Design
Collaborative Model Functional Space Programming
No. Unit Area Net SF Notes Practice Space
Exam Room 82 120 9,840 2 rooms per provider Consult Room 14 120 1,640 1 per 6 exam rooms Procedure Room 10 220 2,255 1 per 8 exam rooms Xray Room 1 400 400 Includes Control Room Cast/Splint Room 1 300 300 2 positions + storage Reception/CheckIn/CheckOut 16 50 820 4 positions per 20 exam rooms Clinical Patient Toilets 8 50 410 1 per 10 exam rooms Staff Work Area (On-Stage) 36 40 1,440 Open, touchdown area, per provider Staff Work Area (Off-Stage) 36 40 1,440 Semi-private area; per provider Public Patient Toilets 8 50 410 1 per 10 seats waiting Waiting Area 82 20 1,640 1 per exam room Soil Utility 4 80 328 Soiled Linens, Trash, Recycle Clean Supply 4 80 328 Clean Supplies, Linens Staff Kitchen 4 60 246 Refrigerator, microwave, coffeemaker Staff Toilet 4 50 205
Staff Lockers 4 80 328 Env Services Closet 4 60 246 Mop Sink Tel/Data Closet 4 60 246
Sub-Total (DNSF) 22,522Departmental Net Square Feet 1.40 Estimated Net to Gross Factor
Total (DGSF) 31,531Departmental Gross Square Feet
Notes:
1. See Common Areas program sheet for shared spaces in building. 2. Support spaces (Soiled Util thru Elec Closet) calculated at approx 1 per 20 exam rooms. 3. Actual or projected Provider counts needed for on-stage/off-stage work areas.
TOTAL No. of Providers = 41
Space Program for Collaborative Practice areas:
Collaborative Model Functional Space Programming
TOTAL No. of Providers = 41
Space Program for Collaborative Practice Building area:
New AreaNotes Department Name
Provider Space 31,53141 providers
Centralized Building Areas:
Entry Vestibule 200
Main Greeting/Reception Desk 150
Main Lobby 400
Public Toilets 200
Large Conference Rm 400
Telehealth Suite 250
Shared Decision Room 200
Nurse Clinic Area 400
Stairwells 4002 @ 200 SF each
Elevators 2002 @ 100 SF each
Elevator Machine Room 150
Security Central 100
Mechanical Room 600
Env Services Central 120
Tel/Data Closet Central 80
Electrical Room 200
Sub-Total (DGSF) 35,581Departmental Gross Square Feet 1.2 Estimated DGSF to BGSF Total (BGSF) 42,697Building Gross Square Feet
+/- 1,000 SF per provider
Design Concept
Cost Comparisons
Project Cost Analysis:
Traditional Design 62,000 SF
Delta in Building Area = 19,000 SF
x Construction Cost psf of $250
Projected Construction Cost Savings =
$4.75M
Extended Project Cost Savings =
$7M
Modular Design 43,000 SF
Potential Operational Savings:
Reduced SF results in Staff & Material savings for Environmental Services & Building Maintenance
Reduced SF results in HVAC & Electrical savings over time
Standardized room design results in streamlined use, inventory (stocking), furniture/equipment selection, etc.
Reduced, non-replicated, supply rooms & standardized inventory results in less waste and over-stocking
Reduced number of exam, consult, procedure room, staff work areas results in less IT spending
Cost Comparisons
Challenges
Issues
Changes
Challenges, Issues, Changes
Primary Focus is the Patient Experience
How do you engage the patient? • Entering the Facility • In Reception Areas • The Clinical Experience • Support Services • Community Destination
How do you consolidate three sites?
Services to be considered:
• Facilities and Environmental services • Patient Access Centers
• Scheduling, Health Information, Financial Counseling
• Registration & Insurance Processes
• Ancillary Services / Single Site / Full Service Multi-Specialty Practice
• Management
Operational Challenges & Considerations:
Challenges, Issues, Changes
Physicians
Desire to maintain the status quo & design by department
Physician office and work spaces
• Learn to work in new technologically based environment • On space, shoulder to shoulder with staff & patients
Staff
Efficient team structure through co-location of like services
Gaining new efficiencies with same staffing levels
New Services
Incorporate external entities that support practice
Maximize efficiency of space utilization (part-time services)
Space for traveling providers
Operational Challenges & Considerations:
Challenges, Issues, Changes
Flow by “Bubble”
Co-location of similar services by floor (Primary Care, Specialties, Ancillaries)
Overlapping of services by floors
Build flexible clinical space to accommodate 75% performance of surgical specialties / match surgical specialties to clinics
Facilitates cross-training between clinical departments
Multi-Functional Rooms
Modularity facilitates change in space
Spaces designed for multiple uses
Prepare for different care delivery models • Telehealth / Telemedicine • Group Medical Appointments • Nurse visits
• Support Services – Behavioral Health, Nutrition, Social Services
Operational Changes:
Challenges, Issues, Changes
Design (planning) models allowing for future design-related or operational model changes/adaptations = flexibility
Lessons Learned:
The Case Study
morris switzer
e n v i r o n m e n t s f o r h e a l t h
■ 220,000 Population of Greater Nashua, NH
■ 70,000 Patients served by Dartmouth-Hitchcock Nashua
■ 225,000 Visits per year
■ $115M Annual Revenues
■ 90 Physicians and associate providers
■ 400 Full and Part Time Staff
Some numbers…
About D-H Nashua
Design Principles
■ Extension of DHMC in Nashua
• Reflecting our Mission, Vision, and Values
■ Quality, Access, Environmentally Responsive
• Professional, light, “green”
■ Patient-centered
• Welcoming, easy to navigate
■ Promoting Teamwork and Medical Home
• Adjacent workspaces
■ Flexible/Efficient
The Project
Level 3
Level 2
Ground Floor
Typical Room Layout
Exam Areas
Infusion
Provider Work Space
Office Area with Lounge
Admitting
Interior Stairs
Signage Depicting D-H Nashua History
Ceiling Detail
Wayfinding through Signage & Monitors
Naturally Lit Waiting Area
Communications
Timeline
■ 2003 Purchase of land at Exit 8
■ June 2009 Trustee approval to proceed Selection of architects
■ Feb. 2010 City of Nashua approves project; Construction managers hired
■ May 2010 Groundbreaking ceremony
■ Nov. 2011 Completion of construction on time under budget
morris switzer e n v i r o n m e n t s f o r h e a l t h Christine A. Schon, FACMPE Vice President, Community Practice Groups
[email protected] dartmouth-hitchcock.org
(603) 629-1120
Jennifer R. Arbuckle, AIA, LEED AP Partner
[email protected] Morrisswitzer.com
