The traditional organisation of clinical work by medical specialism is approaching the end of its useful life, asserted chair of Durrow Health Services Management Andy Black, who kicked off an entertaining trio of presentations looking at theory and practice around re-designing the hospital for the future.
Black pulled no punches in dismantling the current healthcare structure. “The grouping of patients and the organisation of physical space should no longer be on a speciality or departmental line,” he said. “If you take that view, then, at a stroke, the whole basis of hospital planning is nullified. The guides, guidance and experience become a historic vocabulary of language that will no longer be appropriate. There will be no orthopaedic ward; there will be no outpatient department; there will be no physiotherapy department.”
It’s a view, he confessed, that has attracted reactions ranging from laughter to derision to outright hostility.
Under the current system, it’s typically the patient who moves around the hospital, not the staff, yet very few patients will attend for a single clinical intervention. With 350-plus job categories in any hospital, 200-plus physical locations inside the hospital, and three-quarters of hospital expenditure going into wages, the frictional losses in internal co-ordination can be substantial.
“For 30 years,” said Black, “hospital managers have understood that on-duty clinical staff will struggle to exceed 25 per cent of their rostered time doing anything that’s therapeutically useful. This is not a critique of staff; scheduling, transit, clerical work, telephone and answering, and general confusion can mean that a very busy shift achieves very little.
“These levels of productivity would not be considered normal in most other areas of the economy.”
Design principles for the future hospital
The search for a suitable replacement for this model is far from easy, lamented Black, but there are some principles to build on, namely:
There are also three areas that offer promising possibilities for reorganising clinical work: all ambulatory, and diagnostic and interventional surgical episodes that are scheduled; all emergency assessments; and maternity and birthing.
Human and machine dimensions
While stressing that he doesn’t see much merit in experimenting around current practices to improve efficiency, he underlined the imperative to focus on radical experimentation on two dimensions in combination. Firstly, the human skills dimension must be addressed, with Black highlighting something loosely based on the 80:20 principle, where there are staff members capable of dealing with 80 per cent of the most common health issues, and the other 20 per cent based on, perhaps, a more traditional role demarcation line.
The second element is the machine dimension or artificial intelligence. Likening the situation in medicine today as similar to the early days of human chess players pitting their wits against machine opponents, Black said doctors are currently sniggering at the algorithms that the NHS is using. The time will come, however, when these algorithms are as advanced as those in the Jesse 2022 chess engine – a machine that, apparently, is undefeatable by a human player.
“The most important issue thus raises is you now have the ability to simultaneously, in real time, manage a matrix of 400 to 600 acutely ill patients, and to track that what is happening in their therapeutic status is what is expected.
Summing up, Black conceded that the best prospects are likely to “come wrapped in money”, adding: “Hospitals are very expensive; labour is very intensive and it’s grossly inefficient. There is serious money to be made in making hospitals smaller and more efficient.”
Design to inspire activity
Black was followed by two presentations that looked at different approaches to re-engineering the traditional hospital structure around today’s clinical needs. First up was Roelof Gortemaker, director at de Jong Gortemaker Algra (dJGA) Architects and Engineers, who shared his firm’s ‘Reactivating hospital’ and the Holland Health House (HHH) concept. He explained that in a general hospital setting, 85 per cent of people can get out of bed and walk around, but they’re staying bed-bound, as it’s easy for the doctor to know where they are when doing their rounds.
“But we all know that when you spend a few days in bed, you’re already losing muscle strength,” said Gortemaker. “It can be particularly dangerous for an elderly person to spend weeks in bed and lose so much muscle strength. If you spend 10 days in bed, you have aged the equivalent of 10 years in terms of muscle strength. So, we wanted to find a way to improve that.”
HHH is a set of scientifically based practical interventions based on a completely different day schedule and design of the patient environment. Focused on ‘making patients stronger’, HHH shifts the traditional routine of 10 hours’ sleep, 10 hours’ relaxation, and four hours’ activity to a rhythm of eight hours for each. Not only does this require an alternative mindset of patients and staff but a different interpretation of physical space.
The concept, developed as part of a pilot with TNO at Diakonessenhuis Utrecht, did not progress to the implementation stage, but many of the ideas discussed will be executed at another hospital in Maastricht.
Gortemaker explained: “We proposed reducing the bedroom to the smallest possible size, because it would only be used for sleeping and when you have visitors you would not be in your room. There are 26 rooms on the left, and 26 on right, and not all of them are up against the building façade. They all have a window and garden, so you are already ‘out of your room’.”
All eating and dining takes place outside of the bedroom, with two restaurants available. There is also a living room, several gardens and a gym to promote further activity among patients. To assist with the change of mindset, the transition from bed to room, from room to corridor, from corridor to department, and from department to the rest of the hospital is softened, inviting patients to move around and remain active.
In Maastricht, the hospital corridor is redefined as ‘the route of the senses’ – a space when people can indulge in many more activities than simply walking, such as sitting, relaxing and listening to music. More meeting rooms have been incorporated into departments, and there are lounges for watching television and outpatient areas.
Designing for flexibility through lean operational planning
Another perspective on the future hospital was provided by Marvina Williams, senior operational planner at Perkins+Will architects, and her colleague, Elizabeth van den Brink, senior associate, healthcare planner.
They presented a case study on University Health System (UHS)’ efforts to transform the 42-year-old University Hospital in San Antonio, Texas – a journey that began in 2010 – with a state-of-the-art ten-storey tower. Central to the project were design for quality improvement, innovations in technology, and art for healing.
The team established several guiding principles with the client, which were revisited regularly to ensure the design stayed true to the original intentions. Van den Brink listed these as: patient and family-centred care resulting from staff-centred care; maximising operational efficiency and integration within the campus; ensuring fiscal responsibility; providing value for sustainable infrastructure and continuation of operations; leading in energy and environmental design; and ensuring it is an inspiring and welcoming space, and a source of civic pride.
Added Williams: “They wanted it to be a very welcoming place and wanted passive security at the front, so you weren’t greeted by the police, but you were greeted by ambassadors. On the issue of flexibility and efficiency, if you want to be a healthcare facility that thrives and survives, you must be flexible and able to adapt to any change that can develop. So, we tried to standardise as many of the rooms as possible and ensure the same layouts.”
The increasingly high acuity of patients created a need, also, to flex these rooms and have universal beds that could be flexed up to perform high-acuity roles.
Simulation modelling of various flows of healthcare were performed to ensure the hospital would function efficiently. These flows included everything from patient, family and staff flows to equipment and medication flows, to the flow of information.
Focus on the emergency department
Carrying out both a pre- and post-occupation evaluation, the emergency department was a major focus of the project.
“We met the users there and went through the process mapping with them,” explained Williams. “We did simulation studies and came up with future innovations and benefits for them. The design goals that were established by the users were: private universal rooms; flexible clinical space; increased visibility; reduced travel distance; improved patient flow; bedside registration and discharge. They had a medical express clinic for urgent care that they wanted and they put this off site.”
The results of this piece of work have been significant. Before they moved in, in 2013, they were running emergency department ‘door to triage’ times of 65 minutes. When they moved in in 2014, they were down to 24 minutes, and in 2015, six minutes.
Other benefits included: a concierge greeter; provider triage; waiting and sub-waiting areas; decontamination area; flexed space; universal acuity-adaptable rooms; centralised and decentralised spaces; and good collaboration space.
Technological innovations included the use of automated guided vehicles, which have saved the equivalent of 35 full-time employees, an interventional platform, which, among other things, helps manage the sterile processing of around one million instruments each month, while a dashboard in the emergency department displays myriad information to patients, such as length of stay, waiting times, etc. Tele-tracking boards on nursing units provide real-time updates on patient conditions, and integrated operating rooms allow hands-free video conferencing to consult with specialists or teach from the sterile field.
Transitional care unit and a major arts programme
A major success has been the incorporation of a transitional care unit, so much so that another may have to be opened on another floor to meet demand.
Explained Williams: “Once a patient has been discharged on the floor, if they meet the criteria, they will be sent to this area to wait for their family to pick them up. It is staffed by nurses and there is oxygen on the walls if the patient needs that. The nice thing is there is also a medical dispensing kiosk for discharge medications.
The importance of providing an enhanced patient and family-centred environment is also delivered through a major arts programme, with more than 1200 original works assembled to give inspiration and hope to patients and families. Through its Salud-Arte: Art of Healing Program, UHS also helped ensure the art contributed function through wayfinding, with each floor having its own colour scheme, and attention paid to the local San Antonio art heritage and culture.
Concluding, van den Brink said: “We were able to define goals and metrics. We integrated a lot of different design elements: quality improvement; technology; art; all or that simulation; and we were worked as a team.”