National Nurses Week was a timely occasion for EUA to virtually host our annual presentation and discussion with the Advisory Board. This installment was entitled "A New Focus for Health System Facility Strategy." Guiding our discussion was Miriam Sznycer-Taub, a Senior Consultant with Advisory Board’s Health Care Industry Committee.
Miriam first discussed the pre-COVID-19 landscape of health system consolidation: consumerism, population health, and care management driving us toward more sites of care, particularly lower cost outpatient sites; and the move toward system level coordination of services. She then summarized the current conditions associated with the pandemic: the negative financial impact from canceling elective procedures and treatments while not making up those losses with COVID cases; the Federal stimulus package; persistent challenges due to longer term volume erosion from lack of consumer confidence and the larger economic downturn; and finally the challenges associated with re-starting.
Miriam then posed three questions for the future: What will facilities need to repair? How will the design of facilities change? Which types of facilities will systems build in the future? As architects, we at EUA have been actively discussing the second question, so I offer some of our initial thoughts on the matter.
As we look ahead to a post-COVID-19 world, or at least one in which we have a vaccine for the novel coronavirus, we know that unfortunately we will not be “post-pandemic.” Our instincts are therefore to think about how to design for the next pandemic. We also know, however, that healthcare facility design must balance a number of factors, including infection prevention and clinical best practices, but also patient and staff experience, reimbursement structures, and cost, to name just a few. For this reason, although the COVID-19 episode has revealed some shortcomings in our current healthcare delivery system, we will not be able to completely redesign the system or its physical structures overnight, nor should we. We have long included preventing communicable disease transmission in our list of facility design goals, we simply anticipate that this will be a higher priority in the near- and medium-term future.
Pandemic Minded Design Strategies
Pandemics are public health challenges that put enormous stress on healthcare workers, supplies, processes and facilities. Recognizing that all of these must be part of our strategy for improvement, and applying our expertise in facility design, our team has been focusing on potential changes to architectural and interior design. Our primary focus has been on areas where there is already momentum for change, because that is where we anticipate the best adoption. We see several approaches working in concert to further improve our ability to minimize communicable disease transmission. These include reducing patient presentations at the facility, isolating infectious patients who do present, improving the facility’s ability to prevent the spread of infection, and providing surge capacity for high volume episodes.
Minimizing In-Person Visits
Various technologies are available to determine human occupancy levels within a space, including thermal sensors and video capture. Health systems might elect to use these technologies to determine that a facility is at or over capacity, and then redirect patients to other facilities or to a virtual visit. Based on our experience with COVID-19, telemedicine is clearly here to stay; patients, providers, regulatory agencies, and payers are increasingly embracing the benefits. We are studying a variety of options for further incorporation into our clinic designs. For example, we may begin equipping standard exam rooms with video conference technology; we may increase the ratio of virtual visit to in-person encounter rooms; and some systems may begin to re-think the move away from private provider offices, with the understanding that these may double as telemedicine rooms.
Access and Flow
When considering the site plan of a new facility, we will be looking for areas that can be designated for drive-through testing so that patients can be screened before entering the building. For cold climates like Wisconsin and Colorado, vestibules and lobbies can be sized and arranged to provide screening areas. Planning can create one-way and segregated traffic flows, separating screened from unscreened patients and positive from negative test results. General patient traffic can also be segregated from general staff traffic, thereby minimizing unnecessary contact. We anticipate changes to reception and registration areas in order to promote social distancing and minimize exposure of frontline staff to the public, and between members of the public. Similarly, the drive to minimize waiting areas, which have long been considered wasted space, will continue.
In the clinical areas, we anticipate increased adoption of technologies that will help minimize unnecessary person to person contact, including remote physiological monitoring, thermal scanning, and biocontainment. Manufacturers and vendors who have long been providing easy to clean interior furnishings and finishes, will introduce new innovations. Air handling systems will be under increased scrutiny around parameters such as air changes per hour, percentage of outside air and filtering.
The key to designing for surge capacity is flexibility. Although we have seen the creation of many Alternate Care Sites around the country, these facilities present significant challenges to patient and staff safety. Buildings converted from other uses typically lack good sightlines, cleanable finishes, emergency power, nurse call systems, medical gas, proper air changes and filtration, etc. FEMA facilities – typically modular pods set up in convention centers and arenas – lack privacy. Since the most effective surge spaces are within facilities generally already equipped with these features, we expect renewed focus on the acuity adaptable room. These have traditionally meant general med-surg beds equipped with an ICU level of safety infrastructure, but we anticipate this thinking to extend to ASC and Clinic environments as well.
In addition to the general facility design strategies I’ve discussed above, we also expect that numerous operational protocols will be re-evaluated. We anticipate further tailoring our designs to each organization’s emerging best practices in areas such as environmental services, instrument sterilization, materials management, food service and others. Our primary focus has always been on supporting healthcare organizations as they navigate the changing landscape, and I’m available to talk with anyone about potential impacts to your facility design.
Paul Stefanski, AIA, EDAC, LEED AP