During the past several years, federal healthcare reform has combined with a dubious economy to cause many healthcare institutions to delay or reduce capital investment projects and bring focus to operational changes, such as implementation of electronic medical records, to streamline workflow processes in preparation for changes in reimbursement structure. As reimbursement changes from a fee-for-service model to one based on population outcomes, a coordinated focus on those populations will demand greater multi-disciplinary interaction among care providers. Though the rollout of reform legislation is ongoing, one thing is clear: improving efficiency will be essential for healthcare providers going forward.
In a November 2010 report, the Advisory Board described the need to co-locate staff and services typically located in ‘silos,’ noting that “opportunities to share diagnostic equipment, as well as procedural space, will lessen construction costs, while helping spur care collaboration through regular provider interactions.” The report also notes that an open work environment can allow for better interaction among clinicians of all types. As hospitals reconsider capital projects and seek strategies to utilize facilities, equipment and staff more efficiently, several departments offer opportunities to improve efficiency by consolidating services. Technological advancements in surgery, cardiac catheterization and interventional radiology offer potential to explore physical consolidation of shared support services.
Typically these departments are located in separate areas of a hospital or campus, each with their own prep/recovery space and staff, support space such as lockers and lounges, and patient services, such as reception, scheduling waiting, consultation and purchasing. Extensive building corridors connect these areas together across large distances. Because these services require patient sedation or anesthetic, anesthesiology physicians and staff are typically required in these separate areas, requiring either significant travel or staff duplication. Additionally, interventional radiology and cardiac cath/EP procedures, while minimally invasive, will likely require increased sterility levels per changing regulations to minimize risk of infections.
In a 2005 article, architect and author Bill Rostenberg defined the convergence of surgery and IR as “surgology,” putting forth the challenge to healthcare designers to consider how these combined departments may take shape. To date, only a few major academic medical centers have implemented the interventional platform with varied approaches to vertically and horizontally organizing the procedure suite and supporting services such as prep/recovery.
Existing conditions and site notwithstanding, could the integration of interventional services be carried to the point that all procedure rooms are flexible, rooms are served by a single sterile core and patients understand a singular entrance and exit to this range of services? Two design hypotheses emerge based on this question. Physically consolidating surgery, interventional radiology and cardiac cath into a single platform can improve operational efficiency and promote collaboration by consolidating prep/recovery areas and support spaces, combining sterile supply flow to all procedure rooms and collocating staff that work across disciplines. Developing the platform on a universal module with flexible soft space allows procedure spaces to be enlarged or modified with minimal renovation to accommodate evolving procedures and technologies. Expected outcomes include a net reduction in square footage and staff travel due to consolidation of departments, improved patient flow due to consolidation of prep/recovery space, and improved patient and family wayfinding due to consolidation of services and economy of scale.
These hypotheses are currently being tested in schematic design at a large academic medical center in New England. Site constraints include a hilltop site and buildings of varied vintage. Several architectural strategies have developed to respond to conditions, achieve efficiency and create therapeutic spaces and enhance staff collaboration.
If a modular approach to the architecture of a procedure room can address the various functional objectives required, then ability to bring flexibility over the life of the architecture will greatly enhance future needs based on evolving technologies, trends and standard of care. Room flow and function primarily establish the universal room module, while referencing benchmarks and typical equipment specs. Experimentation with full-scale mock-ups and site tours provide users with hands-on involvement in shaping procedure rooms.
Flexible & Modular Platform
Soft spaces allow for breathing room as needs change over time. Modular procedure suite design incorporates an 8-foot flexible zone between every procedure room that is allocated as control, storage or enlargement of specific procedure spaces, such as hybrid rooms.
Interdigitated restricted and sterile circulation
The architecture allows the suite to operationalize as either a ‘clean-core’ or a ‘sterile-core’ model. When operated as a sterile core, one continuous pathway with robotic supply distribution can serve all 43 procedure rooms from sterile elevators connected to Central Sterile below. Likewise, patient and staff circulation occurs in a single network of restricted corridors.
Within the consolidated platform specific procedure spaces are co-located by service line, maintaining proximity to like staff, specialty supplies and organizing patient flow. The economy of scale gained by sharing circulation, sterile supply flow and prep/recovery space need not be at odds with the special requirements of each interventional service line. Greater quality of care may be realized through increased opportunity for interdisciplinary collaboration.
The need to leverage every square foot to its highest potential challenges the notion that corridors are suitable only for circulation and equipment parking in alcoves. Staff often has impromptu conversations in the corridor, and creating nodes for these meetings to occur improves flow and privacy and offers the opportunity to create more dynamic space than a typical 8-foot corridor. Reconceiving restricted corridors as ‘collaboration concourses’ allows for high volumes of stretcher traffic, ‘off-street’ spaces for staff interaction and provides orientation for occupants.
It is important to note potential challenges to the single-level consolidated model. Culturally, this is a significant change toward collaboration in many ways that may be difficult for staff, requiring commitment by senior leadership. Physically, a hospital’s site and context may limit the amount of the model that can exist on a single level, challenging designers to create vertical connections for collaboration. In an existing facility, undertaking a substantial capital project to consolidate services could be challenging. Despite the challenges, the consolidated interventional procedure model offers great potential to enhance collaboration and discovery among surgeons, interventional radiologists and cardiologists and to ultimately improve patient experience.
The Advisory Board. Implications of Reform on Facility Design. 2010, November 11.
Rostenberg, Bill. (2005, June 7). Surgology is Coming! Designing for the convergence of surgery and interventional radiology. Retrieved January 30, 2012, from http://www.hfmmagazine.com
Photos (from top to bottom)
Photo 1: Surgery Concourse Concept
Serving as a primary link between procedural neighborhoods, the restricted corridor can be considered as an off-stage public space providing space for staff collaboration and incorporating elements such as skylighting that are often limited to public lobbies.
Photo 2: Interdigitated Interventional Platform
In addition to separating sterile and restricted flows, this concept allows for procedure areas to be grouped into neighborhoods by specialty, while still sharing major circulation and common support functions.
Photo 3: Full-scale Mock-ups
Utilizing full-size mock-up rooms with moveable walls encouraged user interaction and flow simulation, determining ideal room sizes that help establish the size of the procedure room module. Items such as C-arms can be effectively simulated using basic building materials.
Allen Buie, AIA, NCARB, LEED AP is an Associate and Project Designer in the Perkins+Will Boston office. He approaches healthcare projects in a way that melds planning and design into solutions that are equally poetic and pragmatic. His recent work includes renovations for community hospitals and academic medical centers, campus master planning and creating environments for pediatric and rehabilitation populations. He can be reached at email@example.com.
"Designing for Health" is a monthly, web-exclusive series from the healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments. Past installments of "Designing for Health" include (click on title to access the full article):
The Differences between U.S. and U.K. Clinical Planning Models
Widening a Circle of Natural Inclusion
Mentoring the Next Generation of Healthcare Design Professionals
When the Professional Becomes the Patient--An Insider's Perspective
The Evolving Role of the Design Professional Through Public Private Partnerships
Are Best Healthcare Design Practices Transferable to the Middle East?