9/19/2014. Facility Design with the Patients at the Center. Learning Objectives: A remarkable project

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1 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 morris switzer 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 remarkable project 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 There are no boundaries between practice types Every exam room is identical Vast majority of providers have no hard-walled office 1

2 Overview Collaborative Practice Models Drive Efficiencies in Facility Design: Planning, Operations, and Costs Challenges, Issues, Changes Lessons Learned: The Case Study Collaborative Practice Models: Planning Operations Costs Drivers of Change Healthcare Regulatory changes Legislative drivers Reimbursement models Demonstrated efficiency requirements The Practice Model 2

3 A New Practice Model 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. The Practice Model Medical Home Model Key Elements Teamwork Care Coordination Population Health Metrics Data registry coordination Electronic Health Record NCQA Certification 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 Practice Model 3

4 The Iterative Process Steering Team Makeup User Group Meetings From Individual Needs to Departmental Needs to Collaborative Needs The Practice Model Questions Explored during design process How will our new facility 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? The Practice Model concepts simple clean healing organic natural timeless connection to site connection to community the project 4

5 Two Focus Groups DH patients non-dh patients the project Tools of Communication the blog Questions Explored on the Blog How will our new facility 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? the blog 5

6 Space Programs for Traditional Medical Suite design: 3-Provider Suite 6-Provider Suite 12-Provider Suite Unit Space No. Area Net SF Notes Exam Room Unit Space No. Area Net SF Notes Large Treatment Room Unit MD Office Exam Room Space No. Area Net SF Notes Large Office Manager Exam Room Treatment Room Business Office workstations Exam Room Large Exam Room Nurse draw station Work Area Phlebotomy Station MD/Pract Offices Medical Records Treatment Room Phlebotomy Station draw Offices station Prac Reception/Scheduling Mgr, Billing stations MD/Pract Offices Decentralized Staff Break Room Nurse Work Areas Offices Prac Nurse Mgr, Station Billing Central Supplies/Storage Nurse Work Areas Decentralized Vital Sign Stations Waiting Area Toilet patient/2 Rooms staff people patient/1 staff Nurse Station Central Toilet Rooms Housekeeping Vital Sign Stations Clean Utility Coset Data Closet Toilet Rooms patient/3 Soiled Utility staff Clean Utility Supply Storage Soiled Utility Reception/Scheduling Private booths Supply Storage Admin Work Area Copier, Printer, Sup Reception/Scheduling Private Staff booths Break/Conference people Admin Work Area Copier, Waiting Printer, AreaSup people Staff Break/Conference Housekeeping people Closet Sub-Total (DNSF) 2,740 DNSF Waiting Area Data people Closet Med Records Housekeeping Closet Storage 1.4 Grossing Factor Sub-Total (DNSF) 4,850 DNSF Data Closet Med Records Storage Total (DGSF) 3,836 DGSF 1.4 Grossing Factor Sub-Total (DNSF) 8,830 DNSF Total (DGSF) 6,790 DGSF 1.4 Grossing Factor Total (DGSF) 12,362 DGSF Traditional MOB Functional Space Programming Functional Space Program for Traditional Building area: Individual Practices Family Practice Internal Medicine Oncology OB/Gyn General Surgeons Gastroenterologists Pediatrics Urologists New Area Notes 12, providers 7,000 6 providers 4,000 3 providers 4,000 3 providers 12,000 9 providers 4,000 3 providers 4,000 3 providers 3,000 2 providers Building Areas (general): Vertical Circulation Stairwells, 2 Elevators Mechanical 400 Electrical 200 Maintenance Space 200 Sub-Total (DGSF) Total (BGSF) 51,400 Departmental Gross Square Feet 1.20 Estimated DGSF to BGSF 61,680 Building Gross Square Feet TOTAL No. of Providers = 41 +/- 1,500 SF per provider Traditional MOB Functional Space Programming Floor Plan Diagrammatic Layout for Traditional Planning: Traditional MOB Design 6

7 Space Program for Collaborative Practice areas: Practice Space No. Unit Area Net SF Notes 120 9,840 2 rooms Exam Room 82 per provider Consult Room ,640 1 per 6 exam rooms Procedure Room ,255 1 per 8 exam rooms Xray Room Includes Control Room Cast/Splint Room positions + storage Reception/CheckIn/CheckOut positions per 20 exam rooms Clinical Patient Toilets per 10 exam rooms Staff Work Area (On-Stage) ,440 Open, touchdown area, per provider Staff Work Area (Off-Stage) ,440 Semi-private area; per provider Public Patient Toilets per 10 seats waiting Waiting Area ,640 1 per exam room Soil Utility Soiled Linens, Trash, Recycle Clean Supply Clean Supplies, Linens Staff Kitchen Refrigerator, microwave, coffeemaker Staff Toilet Staff Lockers Env Services Closet Mop Sink Tel/Data Closet Sub-Total (DNSF) Total (DGSF) 22,522 Departmental Net Square Feet 1.40 Estimated Net to Gross Factor 31,531 Departmental 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 Collaborative Model Functional Space Programming Space Program for Collaborative Practice Building area: Department Name Provider Space New Area Notes 31, 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 SF each Elevators 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) Total (BGSF) 35,581 Departmental Gross Square Feet 1.2 Estimated DGSF to BGSF 42,697 Building Gross Square Feet TOTAL No. of Providers = 41 +/- 1,000 SF per provider Collaborative Model Functional Space Programming Floor Plan Diagrammatic Layout for Modular Planning: Design Concept 7

8 Project Cost Analysis: Traditional Design 62,000 SF Modular Design 43,000 SF Delta in Building Area = 19,000 SF x Construction Cost psf of $250 $4.75M Projected Construction Cost Savings = Extended Project Cost Savings = $7M Cost Comparisons 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 8

9 Operational Challenges & Considerations: 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 Challenges, Issues, Changes Operational Challenges & Considerations: 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 Challenges, Issues, Changes Operational 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 Challenges, Issues, Changes 9

10 Design (planning) models allowing for future design-related or operational model changes/adaptations = flexibility Challenges, Issues, Changes Lessons Learned: The Case Study morris switzer environments for health Site Plan 10

11 Some numbers 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 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 4 11

12 Level 3 Level 2 Level 1 12

13 Ground Floor Typical Room Layout Exam Areas 13

14 Exam Areas Infusion Internal Shared Workspace 14

15 Provider Work Space Office Area with Lounge Check-in 15

16 Admitting Interior Stairs Stair Detail 16

17 Signage Depicting D-H Nashua History Ceiling Detail Waiting Area 17

18 Wayfinding through Signage & Monitors Naturally Lit Waiting Area Teleconferencing 18

19 Communications Timeline 2003 Purchase of land at Exit 8 June 2009 Trustee approval to proceed Selection of architects Feb City of Nashua approves project; Construction managers hired May 2010 Groundbreaking ceremony Nov Completion of construction on time under budget Jan Move in! 19

20 Christine A. Schon, FACMPE Vice President, Community Practice Groups dartmouth-hitchcock.org (603) morris switzer environments for health Jennifer R. Arbuckle, AIA, LEED AP Partner Morrisswitzer.com (802)