Matters of the Heart
A proliferation of specialty hospitals, predominantly cardiology, oncology, and orthopedic facilities, are adding fuel to the fire that is the red-hot healthcare market.
Lured by the opportunity to escape from under the thumb of managed-care facilities, which dominated healthcare in the 1990s, physician groups in recent years have jumped ship from nonprofit community hospitals to for-profit healthcare providers.
These specialists say they have grown tired of being subject to the whims of bean counters and administrators when it comes to deciding on the level of care given to patients, and that they're weary of vying for funds, equipment, and facility time with other departments.
More and more of these highly prized specialists are leaping at the chance to call their own shots, gain more control over how they practice medicine, and share in the profits.
At the same time, more-progressive physician groups are looking at this new independence as an opportunity to build some of the most advanced patient-centered, state-of-the-art facilities. They are using design to enable the kind of patient care they feel they could not provide at their former hospitals.
In response to the mass defections of cardiologists, some multiservice hospital networks are moving to retain their specialty service physicians and stem the flow of revenue-generating services out of their doors by partnering with their cardiology groups to create for-profit heart hospitals, often right on their own campuses.
Oklahoma Heart Hospital in Oklahoma City, which opened last August; Indiana Heart Hospital in Indianapolis, which opens this month; and Wisconsin Heart Hospital in Wauwatosa, to open in 2004, have followed this blueprint.
These heart hospitals also are a microcosm for the move toward healthcare facilities designed to render healthier patient outcomes and improve medical staff efficiency and satisfaction. In years past, holistic design elements such as skylights and fountains often were considered luxuries and value engineered out of hospital budgets. Not so any longer, says Robert Levine, vice president and general manager of Turner Construction Co.'s Nashville, Tenn.-based healthcare division: "We see now that these elements are needed. When a hospital has more program than it can afford, we find a way to pull money out of the job without affecting these things."
"Most hospitals are designed for functionality and technology. But today, hospitals are meeting the environmental needs of patients and staff," says Joy Fay, director of clinical operations for the cardiovascular comprehensive critical care (CCCC) unit at Clarian Health Partners' Methodist Hospital campus in Indianapolis.
"Hospitals are looking at the softer side of technology," says Fay. "They're combining 'high touch' with high-tech. Even though the hospitals are very technologically advanced, they're also aesthetically pleasing."
Four years ago, Clarian joined the vanguard of cardiovascular healthcare design when it combined the coronary critical care unit and coronary medical step-down unit from its Indiana University Hospital into its Methodist Hospital campus. The result was a 56-bed "future-state patient room" CCCC unit on two completely renovated floors at Methodist.
A heart-focused unit within an existing nonprofit community hospital, the $13 million project is a precursor to the freestanding, for-profit heart hospitals. Its patient- and caregiver-focused design, backed by evidenced-based study, is a forerunner of the environment-based designs being implemented in these facilities.
Unit's design based on motion
Significant challenges faced Clarian as it considered combining its coronary units. Hamstrung by a critical nationwide nursing and workforce shortage, located in an intensely competitive marketplace, which soon would include three other new or expanded cardiovascular facilities, and serving an aging and demanding Baby Boomer population, officials considered trying something different in the way of design.
"It's clear that the environments we've been used to won't suffice in the future," says Ann Hendrich, MS, RN, a healthcare consultant and the former nurse executive and senior vice president for Clarian's Methodist campus. "If we continue to design these hospitals and nursing units the way we have, then we're destined to repeat current inefficient designs for the patient and caregiver in the future. The environment is one of the untapped opportunities for healthcare."
To understand what nurses really do with their time, Hendrich videotaped 1,000 hours of them at work. To her amazement, she found that caregivers spent less than 10% of their time actually caring for the patients. The bulk of their time involved "hunting and gathering" tasks, such as fetching linens and supplies.
"It was discouraging," says Hendrich, who notes that lack of time for patient care and workload are leading causes why nurses leave the profession. In the old units, Hendrich says nurses walked three to six miles per day per nurse. "We must reduce the time and distance and increase efficiency to return the caregivers to their patients," she says.
Hendrich also found that patients often were moved to nursing units three to five times during their hospital stay. More than 20 steps are involved in preparing and moving a patient, requiring on average of about 56 minutes of direct caregiver time. Transports cost Clarian $200-$300 per transfer, and can account for more than $5 million to $10 million a year in direct labor and equipment costs, not to mention disruption of care and added patient stress.
Armed with this information, the hospital formed an interdisciplinary team comprised of administrators, physicians, nurses, facilities managers, and dietary, pharmaceutical, and physical therapy staff, to evaluate current and future needs of the unit. Goals for the new environment were set to reduce time and distance of travel by caregivers and to create a healing environment for the patient and family.
Toward this end, the interdisciplinary team worked with locally based BSA Design Inc. as architect, engineer, and interior designer on the project. "We made it clear from the start that this was not going to be the usual nursing unit design," says Hendrich. "We found BSA to be very open and supportive of a different process. To be open to different thinking is key to innovating for the hospital and for the designers."
One patient, one adaptable room
The result of this collaboration was the acuity-adaptable patient room, where a patient is admitted and discharged from the same room without having to be moved to another room as his or her condition changes. "The universal rooms spurred Ann's thinking, and away we went," says Donald Altemeyer, BSA chairman. "Ann and her staff were very enlightened and aggressive."
Patient rooms are family focused and designed to bring services to the patient, says Altemeyer. All rooms are private and large — 400 sq. ft., with 120 sq. ft. of family space, including a sleeper sofa for 24-hour visitation, locker space, mini-refrigerator, and a telephone with Internet connection and private voice mail. Family members are greeted at a reception desk at the entrance to the unit, where family retreat areas and a learning center are provided.
Flexible headwalls above the patients' total-care beds are critical-care ready and feature redundant multigases and outlets on each side of the bed to increase the caregiver's efficiency of movement. Similarly, linens are stored in each room instead of in a central storage area. To promote patient mobility and reduce falls, toilets are located nearer the patient.
Room shapes are varied. The emphasis is on natural light, color, quiet, and a connection with nature. The patient has control over noise and temperature control. A high-tech interior window can be controlled automatically by the patient, making it opaque, and thus balancing patient privacy with the need for observation by the nursing staff.
Nursing stations are decentralized, allowing fewer nurses to care more directly for more patients. "When you're more efficient with the environment, you can improve nursing hours per patient day because you're returning that time to the patient and the nursing process," says Hendrich.
At first, the nursing staff had difficulty adjusting to the new environment. "They didn't like the increased family contact," says Hendrich. Decentralized nursing stations also require more autonomous thought from caregivers, says Fay. In the first year, 30 nurses left the unit. But Fay says the unit now is popular with nurses, and some that left the first year have since returned. "Over time, adjustments were made and there has been very little turnover," says Hendrich. "The benefits for future care delivery are going to far outweigh the risks of losing a small number of staff."
The risks are paying off. Patient transfers have been reduced from about 190 a month to less than 20. Patient falls have been reduced by 80%. Medication errors have decreased from 9.8 per thousand patient days to 3.2. Patient dissatisfaction has fallen from a 6.7 rating to 2.7.
In addition, Hendrich says the unit handled more patient days and admissions using seven fewer beds (56 beds versus 63 beds) than the previous two units that were merged. "With acuity-adaptable rooms, hospitals can be more efficient and have fewer beds," she says. "That's a significant message for CEOs and nurse executives because it addresses the broader issues of cost, access, and capacity. Less geography equals less overhead and reduced labor costs."
Digital at the heart of care
Combining good business with patient care and caregiver efficiency is a common goal of Oklahoma Heart Hospital, Indiana Heart Hospital, and Wisconsin Heart Hospital. All three apply many of the design philosophies incorporated into Clarian's CCCC unit: acuity-adaptable beds, decentralized nursing stations, patient-focused care that encourages family interaction, and a holistic environment from entry lobby to operating room. Yet, each Building Team arrived at its specific designs by considering the needs and mission of the individual hospital.
During its design phase, officials from Oklahoma Heart Hospital toured the Clarian CCCC unit. The $74 million, 230,000-sq.-ft. facility, which opened last May, contains 78 beds. The three-story hospital is the result of a 51/49 joint venture of Mercy Health Center and Oklahoma Cardiovascular Associates (OCA).
Though open less than a year, the hospital has seen improvement in the rate of recovery of many of its patients, says CEO Michael Schroyer. Improved patient care was exactly what the cardiovascular physicians group had in mind when the 22-member organization began considering building its own heart hospital. "We wanted to have a say in patient care and nursing care," says Dr. Ron White, OCA president.
A six-member OCA steering committee worked with Houston-based Watkins Hamilton Ross (WHR) to benchmark and design the hospital. A premium was placed on technology and patient-focused care.
Hospital officials say it is one of the first in the U.S. to be digitally based, meaning patients, physicians, and nursing staff can use high-resolution digital monitors in patient rooms and throughout the hospital to access clinical information — not just text, but also images. Secured through a privacy network, the system even allows physicians to log on from their homes.
White says the paperless technology improves efficiency and legibility of orders and lessens the possibility of medication errors.
Located on a high-profile site along a tollway on the Mercy campus, the hospital features a four-story glass-enclosed atrium lobby that looks out onto the Oklahoma prairie. A concierge desk directs patients and family to the day-bed area.
"A large percentage of healthcare in heart hospitals is outpatient oriented, so a lot of procedures are performed in the cardiac catheterization labs," says Barry Bruce, senior designer on the project for WHR. "The patients are in and out in one day."
To increase efficiency and reduce stress, patients are interviewed, admitted, prepped, and recuperated in one of 16 private rooms.
The only time patients are transferred from their rooms is to undergo the catheterization procedure in one of five labs on the first floor. The hospital's four operating rooms are located next to the catheterization labs. For economy of design, the labs and operating rooms share a lot of facilities, such as lockers and staff lounges.
The second floor houses 62 private inpatient rooms, which are complete with total-care beds, redundant headwall fixtures, and family zones. The rooms are arranged in eight-bed pods with two decentralized nursing stations for each pod. The pod system keeps nurses and patients closer and prevents the larger single-bed rooms from making the hospital too linear, says Bruce. "One station for four beds instead of 40," he says. A dedicated elevator transports patients between the first-floor operating room and the second-floor inpatient unit.
Physician offices are located on the third floor of the hospital, which also contains 16 additional patient rooms.
White says that the pod system, which WHR brought to the table, has helped caregiver morale. "We don't burden the nurses with too many patients per nurse, so they can provide proper care," he says.
"The main thing is the design of the environment," says Bruce. "Now we can point to the evidence on outcomes. We can point directly to the use of glass and healing gardens. These things contribute to the overall health of the patient."
'Hurricane' hits Indiana
When it opens on Feb. 14 — that's right, Valentine's Day — Indiana Heart Hospital hopes to propel itself to the forefront of the hyper-competitive cardiovascular services market in Indianapolis. With the city's three other cardiovascular service providers upgrading their facilities, Community Health Network (CHN) formed a partnership with Indiana Heart Associates, a local cardiology group, to build the $60 million, 210,000-sq.-ft. hospital on the campus of Community Hospital.
Until now, CHN's cardiovascular services have been "one of the best-kept secrets" in Indiana healthcare, says Dr. Michael Venturini, chief of medical services for the heart hospital and a member of the hospital's board, whose representation is split 60/40 between CHN and Indiana Heart Associates. "We've been the second- or third-largest heart program in Indiana for years, but we haven't marketed ourselves very well," says Venturini. The network now has a freestanding, four-story hospital (the unfinished fourth floor will accommodate future expansion) on a highly visible site off a major expressway.
The hospital enables CHN to centralize its cardiovascular care. "As a for-profit, physician-owned facility, the hospital can offer better care," says David Veillette, the hospital's CEO. "Doctors want to be able to have some control and take care of their patients the way they need to be taken care of, instead of being told how" by administrators.
To design the project, the hospital enlisted the Dallas office of Baltimore-based RTKL Associates Inc., known for its design of the Texas Heart Institute. The firm analyzed the hospital's data projections and procedural volumes and examined clinical efficiencies, patient and staff satisfaction, and supply and labor benchmarks to establish a benchmark design.
Like Oklahoma Heart, Indiana Heart marries an environment-based design with all-digital technology. The hospital, which contains more than 650 computers, is paperless and filmless, allowing test results to be immediately added to a patient's chart. The technology also eliminates repetition of patient information and duplication of data collection and entry. Bedside computers keep caregivers closer to patients. "I am not the least bit excited about having a new state-of-the-art facility," says Venturini. "What's exciting is that these new tools are giving us an opportunity to improve the way we do things."
A trademark of the hospital is its "hurricane design" — resembling the whirling shape of a hurricane as seen from a satellite (See floor plan). The design increases caregiver efficiency by reducing walking distances and allowing cross-coverage between nursing pods because the nurses can see into many patient rooms. "The hurricane design has never been done before because it was designed to the specific benchmarks for this hospital," says John Castorina, RTKL's principal in charge of design and lead designer on the project.
The 120-bed facility is divided into eight-bed pods with decentralized nursing stations. "Those pods have everything the nurses need so they don't have to leave the station or the patient bedside," says Veillette. "When you marry the digital with the design, it's very functional. Without the technology, we couldn't have decentralized the nursing stations."
Because it is critical for open-heart patients to become ambulatory within 12 to 24 hours after surgery, the inpatient unit includes an ambulation area and temporary family lounges outside patient rooms.
"The great thing is that we didn't just throw up a hospital building," says Venturini. "We approached it with the idea of reducing redundancies and providing better care."
Outpatients: Where the action is
Technological advances in cardiovascular equipment and procedures prompted Wisconsin Heart Hospital officials to think out of the box in the design of the two-story, 127,000-sq.-ft. facility scheduled to open in January 2004.
The shift to less-invasive catheter-based procedures is reducing the need for open-heart surgeries. With this in mind, officials at the $44 million heart hospital, a joint venture of Milwaukee-based Covenant Healthcare, a local cardiology group, and local business investors, worked with the Chicago office of HDR Inc., Omaha, Neb., to design a facility focused on outpatient care. "The world of healthcare is going less invasive," says hospital president Norma McCutcheon.
In a move McCutcheon says surprised even HDR, the hospital's working group decided it wanted to locate the facility's operating room suites on the second floor adjacent to the inpatient rooms. In most newer freestanding hospitals, including Oklahoma Heart and Indiana Heart, operating rooms are located on the first floor adjacent to the catheterization laboratories, allowing for contingencies in the event of an emergency and for lockers and staffing.
"The location of the ORs was probably our biggest struggle," says McCutcheon of the hospital's relationship with HDR. "We were turning the concept [of healthcare design] on its head."
"The center's design was better served by placing the surgery department on the upper level near the inpatient rooms," says Michael E. Tangney, senior healthcare designer for HDR's Dallas office. "This made the most sense because these patients are electively scheduled and will stay for a longer duration." A tight site plan also made it difficult to fit operating rooms on the first floor.
Redundant support areas will be created on the first and second floors. In an emergency, one of the catheterization labs is equipped to double as an operating room.
Even without the beneficial outcomes of these efforts for patient — and there are many — the design process itself — by bringing medical, nursing, and administrative staffs to a consensus on mission and strategy — has helped foster a sense of cooperation and joint purpose that is making these institutions stronger. In the larger sense, these structures are reflective of the powerful transformations under way across the healthcare industry. The role of architects, contractors, and engineers only will become more critical to the healthcare process in coming years as the industry struggles to provide better work environments for nurses and other caregivers, more humane conditions for patients' family members to contribute to the healing of their loved ones, and most importantly, the best possible care for patients.