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
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
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
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
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
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 6 130 780 Unit Space No. Area Net SF Notes Large Treatment Room 1 150 150 Unit MD Office 3 150 450 Exam Room 10 110 1100 Space No. Area Net SF Notes Large Office Manager 1 100 100 Exam Room 2 130 260 Treatment Room 1 150 150 Business Office 2 80 160 2 workstations Exam Room 20 110 2200 Large Exam Room 2 130 260 Nurse draw station Work Area 1 150 150 Phlebotomy Station 1 120 120 1 MD/Pract Offices 6 120 720 Medical Records Treatment Room 2 150 300 1 150 150 Phlebotomy Station 2 120 240 2 draw Offices station Prac Reception/Scheduling Mgr, Billing 2 60 120 2 stations 2 120 240 MD/Pract Offices 12 120 1440 Decentralized Staff Break Room 1 150 150 Nurse Work Areas 6 60 360 Offices 3 120 360 Prac Nurse Mgr, Station Billing 1 100 100 Central Supplies/Storage 1 60 60 Nurse Work Areas 12 60 720 Decentralized Vital Sign Stations 3 40 120 Waiting Area Toilet patient/2 Rooms staff 10 3 20 50 200 10-12 people 150 2 patient/1 staff Nurse Station 2 100 200 Central Toilet Rooms 6 50 300 4 Housekeeping 1 60 60 Vital Sign Stations 6 40 240 Clean Utility 1 80 80 Coset Data Closet 1 60 60 Toilet Rooms 8 50 400 5 patient/3 Soiled Utility staff 1 80 80 Clean Utility 2 80 160 Supply Storage 1 100 100 Soiled Utility 2 80 160 Reception/Scheduling 4 80 320 Private booths Supply Storage 2 100 200 Admin Work Area 1 80 80 Copier, Printer, Sup Reception/Scheduling 8 80 640 Private Staff booths Break/Conference 10 20 200 10-12 people Admin Work Area 1 150 150 Copier, Waiting Printer, AreaSup 15 20 300 15-20 people 1 60 60 Staff Break/Conference 15 20 300 15-20 Housekeeping people Closet Sub-Total (DNSF) 2,740 DNSF Waiting Area 25 20 500 25-30 Data people Closet 1 60 60 Med Records 1 100 100 Housekeeping Closet 1 80 80 Storage 1.4 Grossing Factor Sub-Total (DNSF) 4,850 DNSF Data Closet 1 80 80 Med Records Storage 1 200 200 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 12,000 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 600 2 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
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 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) 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 31,531 41 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 400 2 @ 200 SF each Elevators 200 2 @ 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) 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
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
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
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
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
Level 3 Level 2 Level 1 12
Ground Floor Typical Room Layout Exam Areas 13
Exam Areas Infusion Internal Shared Workspace 14
Provider Work Space Office Area with Lounge Check-in 15
Admitting Interior Stairs Stair Detail 16
Signage Depicting D-H Nashua History Ceiling Detail Waiting Area 17
Wayfinding through Signage & Monitors Naturally Lit Waiting Area Teleconferencing 18
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 Jan. 2012 Move in! 19
Christine A. Schon, FACMPE Vice President, Community Practice Groups Christine.A.Schon@Hitchcock.org dartmouth-hitchcock.org (603) 629-1120 morris switzer environments for health Jennifer R. Arbuckle, AIA, LEED AP Partner Jarbuckle@morrisswitzer.com Morrisswitzer.com (802) 878-8841 20