architecture: space planning and the development process
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Myra Gray Fouts Natalie C. MiovskiRN, MSN, OCN, CNAA AIA, LEED AP VP, Medical Affairs PrincipalAptium Oncology Inc. EwingCole
Architecture: Space Planning and The Development Process
Sponsored by: Sponsored by: AptiumAptium OncologyOncology
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National Healthcare Expertise 300+ Professionals (Philadelphia, PA, Washington, DC, Irvine, CA, Cleveland, OHHealthcare Strategic/Master Planning, Planning & Programming, LEED Design, Architecture, Interior Design, Cost Estimating, Program Management, Structural, Mechanical/HVAC, Electrical, Plumbing, Fire Protection/Life Safety Engineering,
Natalie C. Miovski, AIA, LEED APPrincipal EwingCole
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Cancer Treatment Centers of AmericaCedars-Sinai Medical CenterChildren’s Hospital of New YorkCity of Hope Medical CenterClara Maass Medical CenterDeborah Heart and Lung CenterFox Chase Cancer Center Geisinger Health SystemLoma Linda Cancer Institute
Memorial Sloan-Kettering Cancer CenterNorth Shore Long Island Jewish Health SystemSaint Jude Children's Research HospitalSanford Children’s HospitalSUNY, Stony BrookUniversity of California, Irvine Medical System
EwingCole HealthcareRepresentative Clients
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Aptium works with hospitals and physicians to design, finance, build and manage comprehensive cancer centersAptium’s comprehensive cancer center model brings all the disciplines and services involved in cancer care under one roof.They are customized to their market; tailored to their situation.
Myra Gray Fouts, RN, MSN, OCN, CNAAVP, Medical Affairs, Aptium Oncology Inc.
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Host Hospitals IncludeCedars-Sinai Medical Center CALIFORNIA
Alta Bates Summit Medical Center CALIFORNIA
St. Vincent’s Hospital Manhattan NEW YORK
Desert Regional Medical Center CALIFORNIA
Mount Sinai Medical Center FLORIDA
Boca Raton Community Hospital FLORIDA
New York University Cancer Institute NEW YORK
Trinitas Hospital NEW JERSEY
The Aptium Network
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Demand for Services How to Measure SuccessTeam, Team, TeamApproach
Planning/developmentDesignConstructionResults: Case Study
Trinitas Comprehensive Cancer Center
Agenda
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A growing demand for servicesAn explosion of treatment optionsUncertain financial climateIncreasing administrative burdens
Future of Cancer Care
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Raise the level of cancer care in the communityIncrease regional presenceRetain and attract leading physiciansFurther enhance research programs and clinical protocols
Increase cancer program profitability and cash flowsDecrease patient out-migrationExplore opportunities to partner with a 3rd party to meet objectives
Proven expertiseAccess to funding
Common Hospital Service Line Goals
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11%
16%
23%
27%
29%
30%
37%
40%72%
0% 20% 40% 60% 80%Capacity
Patient Satisfaction
Government Mandates
Patient Safety
Quality
Personnel Shortages
Care for Uninsured
Physician and Hospital Relations
Financial Challenges
Source: Modern Healthcare, January 1, 2007
Pressures on HospitalsCEO Top Concerns
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Patient satisfaction“I find it very relaxing even though circumstances dictate anxiety.”“Your staff is the most compassionate, caring and courteous medical staff I have ever encountered; each and everyone of themtreats you as a special person.”“You should be extremely proud of your facility and of your magnificent staff!”
How To Measure Success
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9793.7
95.4
90.5
95.3
90.2
95.4
91
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60
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100M
ean
Sco
re
Facility cleanliness Find way aroundfacility with ease
Waiting area comfort Changing roomprivacy
*PG Database = All facilities in Press Ganey's Outpatient Oncology Database
TrinitasPG Database*
Results Overall Consensus - Positive
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Patient satisfactionStaff satisfaction
“Everyone was surprised and delighted with the way it turned out”“What I need to do my work is convenient to me. I turn around and there’s my supplies, my computer, my pharmacy, my patients.”
How To Measure Success?
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Patient satisfactionStaff satisfactionMarket share
How To Measure Success?
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Patient satisfactionStaff satisfactionMarket shareRevenue Realization
How To Measure Success?
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Vision and MissionCharged with:
Fiscal accountabilityOperational efficiencies, flowEvaluating and challenging design concepts
Enhance user group participationPowerful voice/cheerleader
Team, Team, Team
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ManagementFinance / medicine / nursing / cancer center administration
Project champion / forward thinkersExecutive leadership representative
Healthcare architectQuality management peopleGuest servicesFacilities management
Team, Team, TeamMulti-Disciplinary Think Tank
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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Develop detailed business case includingClinical program recommendationsStaffingEquipmentSpace requirements
Approach: Program
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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PatientViews of nature, daylight and sunlightControl of local environmentSocial supportPrivacyNurse visibilityPlaces for family/guestsTranquil, state-of-the-art environment
StaffPatient visibilityMinimal footsteps to key areasSingle point access to pharmacyCollaboration with other nursesSpace for private conversationsAmple supplies near at handPlaces for personal effectsErgonomics
Approach: Model Cancer CenterRecognized Convention
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“It is the unqualified result of all my experiences with the sick, that second only to the need of fresh air is their need of light; that, after a close room, what hurts them most is a dark room.”
– Florence Nightingale
Approach: Model Cancer CenterRecognized Convention
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Equipment & TechnologyLatest, greatest, fastest, smallest, lightestFlexibleComprehensive & user friendly
ArchitectureAppropriate imageCost sensitive
PhysiciansConvenience, convenience, convenienceEfficiencyPrivacyMarketableHigh-technology
Administration/Executive LeadershipRevenue generating spaces
Approach: Model Cancer CenterRecognized Convention
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The Advisory Board – Oncology Roundtable Data
Approach: Model Cancer CenterRecognized Convention
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PrivacyIndividual dignity vs staff supervisionCare givingIncorporation of family responsibilities vs. solo staff tasks
LightingDim vs bright
Noise controlSound attenuation vs hard, cleanable surfaces
Views of natureWindow vs interior viewPatients vs staff
ArtNature vs modern/abstract
Approach: Model Cancer CenterInherent Contradictions
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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Approach: Key Facility Influencers
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MarketCompetitive environmentPatient expectation/quality
Physician ConsiderationsPhysician practice patternComprehensive centerNumber of physicians
Staff RecruitmentRetention
Clinical ProgramsPsychosocial services/ palliative careResearchIntegrative medicineTumor site program
Technology Electronic medical recordsComputer savvyPatient tracking
Space/RegulationExpansion potentialJCAHO/DOH/DCA/OSHPDSite considerations
Approach: Key Facility Influencers
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Approach: Key Facility Influencers
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URBAN RURAL
Approach: Market & Space/RegulationPrivacy Expectations
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URBAN RURAL
Approach: Physician Consideration & StaffPhysician Practice Pattern & Staff Flow
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URBAN RURAL
Approach: Clinical ProgramMulti-Disciplinary Environment
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URBAN RURAL
Approach: TechnologyInformation/Patient Tracking
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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Improved efficiencies
Process re-engineering
Cultural transformation opportunity
Approach: Processes
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“The flow for the patients has been well thought out, not only to reduce patient apprehension, but to help the staff coordinate their care.”Chief, Radiation Oncology
Approach: Processes
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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Schematic design (planning) 15%Design clarifications 25%Construction documents 40%Construction administration 20%
Approach: Design DevelopmentPercentage of Work/Fee by Architecture Firm
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PharmacyRegulatory - sterile compounding (USP 797)Engineering – clean room ISO class 05Material management - storage, deliveriesEnvironmental services - patient/pharmacy safetyArchitecture – door, millwork, ceiling, lights, aesthetics
Approach: Design DevelopmentRoom & Equipment Planning
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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Project delivery methodsDesign-Bid-BuildConstruction managementDesign-Build
Approach: Timeline
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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Budget Value matrixCost containmentManage expectations
Approach: Construction/Cost
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Northeast Urban Cancer Center – 2007 costs Medical oncologyInterior fit-out only $340/sf
Northeast Suburban Cancer Center – 2005 costsMedical & radiation oncology New building $435/sf
Southwest University Cancer Center – 2007 costsMedical oncologyInterior fit-out only $320/sf
Median range (2007) $210-360/sf fit-out only$250-480/sf new building
Pharmacy fit-out only $850/sfLinear accelerator only $450/sf
Approach: Construction/Cost
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National Median 2Cost per square foot: $240Size: 64,000 square feetTotal cost (excluding land): $16.4 M
~$250 per sq. ft.~$200 minimum per sq. ft.highly variable by location
Approach: Construction/CostThe Advisory Board
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Vaults$275–$350 per sq. ft.$25K+ for door3,500–6,000 sq. ft. per vault
Infusion Center$200–$225 per sq. ft., often 1/4 of facility space500 sq. ft. exam room350–500 sq. ft. per infusion space, 350 sq. ft. additional for open bay layout
Clinical Office Space$180 per sq. ft.
Shell Space$60–$90 per sq. ft.
Approach: Construction/CostThe Advisory Board
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-
Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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300-bed Community Hospital with religious affiliationsUrban and inner city neighborhoodProminent location on campus and in cityAward winning economic re-development organizationFormer location of parking lot/original hospital chapel
Approach: Post-OccupancyCase Study: Trinitas Comprehensive Cancer Center
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Specific challenges:Changing use and programNew management teamPredetermined design/construction teamFixed exterior designFast track construction with construction weariness and boom in areaPreset budget and schedule
Approach: Post-OccupancyCase Study: Trinitas Comprehensive Cancer Center
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MarketCompetitive environment 3 (U1 R5)Patient expectation/quality 3 (U1 R5)
Physician ConsiderationsPhysician practice pattern 3 (U1 R5)Comprehensive center 3 (U2 R3)Number of physicians 4 (U1 R3)
Staff Recruitment 3 (U3 R2)Retention 5 (U1 R5)
Approach: Post-OccupancyCase Study: Trinitas Comprehensive Cancer Center
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Clinical ProgramsPsychosocial service/palliative care 3 (U2 R1)Research 2 (U1 R3)Integrative medicine 1 (U2 R3)Tumor site program 3 (U1 R2)
Technology Electronic medical records 1 (U1 R5)Computer savvy 1 (U3 R3)Patient tracking 3 (U3 R2)
Space/RegulationExpansion potential 4 (U1 R2)JCAHO/DOH/DCA/OSHPD 3 (U2 R3)Site considerations 2 (U1 R1)
Approach: Post-OccupancyCase Study: Trinitas Comprehensive Cancer Center
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What works well? Why?What does not work? Why?What was missing?What would have made it easier?Recommendations for improvementWhat would we do again?
ANSWERS HAD TO BE OBJECTIVE
Approach: Post-OccupancyQuestions To Be Answered by Users
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Patient spacesStaff spacesHealing environmentFlow/processes
Approach: Post-OccupancyResults Graded: Facility Design
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Model Cancer CenterProgram
Key Influencers
Processes
Design DevelopmentPost-Occupancy
Patient & StaffSatisfaction
Construction/ Costs
Timeline
Approach
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What kind of culture did we create?“A culture where patients feel cared for and about”
Is it the ideal place for patients to be treated and for physicians to treat patients?
“Yes, given the space available”
Is it a healing environment?“Yes, but could have more water features, gardens etc., to add to the concept”
Approach: Patient & Staff SatisfactionDid We Accomplish Our Goal?
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All areas would have liked more spaceCommon theme included:
Bigger conference roomsIdeally would be all on 1 floor – patients find multi-levels confusingStaff lounge area too small (not enough seating those who need to eat at the same time – not enough for growth)“We’ve already outgrown the space”
Approach: Patient & Staff SatisfactionAcross The Board
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When asked: “What should have been eliminated to make more space for “x”?”
No one could identify what should have been left out or identifyother priorities for space available
Approach: Patient & Staff SatisfactionAcross The Board
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“A nice warm experience for patients and staff”“Patients are very happy”“Patients feel like they aren’t coming to a hospital or a clinical environment”“Patients love it”“Everyone was surprised and delighted with the way it turned out”
From Post-Occupancy Staff Interviews
Approach: Patient & Staff SatisfactionOverall Consensus - Positive
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9793.7
95.4
90.5
95.3
90.2
95.4
91
50
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90
100
Mea
n S
core
Facility cleanliness Find way aroundfacility with ease
Waiting area comfort Changing roomprivacy
*PG Database = All facilities in Press Ganey's Outpatient Oncology Database
TrinitasPG Database*
Results Overall Consensus - Positive
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“The center is always very clean, it is very easy to go from one place to another it is always labeled, the privacy of the changing rooms is very good.”
“I find it very relaxing even though circumstances dictate anxiety.”
“It feels like someone cared about me - everything from the valet parking to the wireless internet”
“The first time they told me about the Center, they said it was like a hotel and not a hospital. When I saw it, I found out that what they said was true. I felt like I was the only patient there with all the attention I received.”
“Hospitality and attention to details are the hallmarks of the patient-centered care at Trinitas”
“All the natural light makes such a difference, I don’t feel like I’m in a cancer center” From Trinitas Cancer Center Press Ganey
Patient Satisfaction Data & Patient Interviews
Approach: Patient & Staff SatisfactionOverall Consensus - Positive
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Myra Gray FoutsRN, MSN, OCN, CNAAVP, Medical AffairsAptium Oncology Inc.8201 Beverly Blvd.Los Angeles, CA 90048Tel: [email protected]
Natalie C. Miovski AIA, LEED APPrincipalEwingCole100 N 6th StreetFederal Reserve Bank Bldg.Philadelphia, PA 19106Tel: [email protected]
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