Existing space in hospitals is a valuable resource that historically has been overlooked as organizations focus on renovating and expanding their physical plants. With fluctuating workloads, rapidly changing technology, staff turnover, and limited access to capital in today’s dynamic healthcare environment, hospital leaders are increasingly looking for ways to better use what they already have. They are also committed to building flexible space when they do renovate or start from scratch.
Improving space utilization begins with a thorough understanding of how existing space is allocated and used. You can then identify opportunities to improve the capacity or throughput of expensive clinical space, reassign underused space to increase its usefulness, and look for alternate and unconventional ways to accommodate programs and services both on- and off-campus.
START WITH AN INVENTORY
All space is not the same. An inventory of existing space should be organized by major category or type of space, because each category may have distinctive building code compliance requirements, renovation or construction costs, and reuse potential. Inpatient nursing units, diagnostic and treatment services, customer services, physician offices and clinics, administrative office suites, and building support spaces are not necessarily interchangeable. For example, space that was designed for outpatient care exclusively cannot be used for inpatients without costly modifications such as widening corridors or providing enhanced smoke and fire barriers.
Space can more easily be down-graded — say, converting a vacated inpatient nursing unit to an office suite or outpatient clinic — than upgraded. However, due to the modular layout of patient rooms, with contiguous patient toilet rooms, converting that nursing unit may either result in an inefficient use of space or require high renovation costs to reconfigure the walls and corridors. Space occupied by one department or functional component within a category can usually be more cost-effectively reallocated for use by another department in that same category. Also, the grouping of departments that have similar facility requirements often exposes new opportunities for the sharing or cross-utilization of space between organizational entities.
MAKE MAXIMUM USE OF EACH SPACE
Now you are ready to explore a range of possibilities for making the space you have work better for your current and future needs.
Increase the capacity of major diagnostic and treatment services. Before committing major dollars to expand an existing department, ask yourself two key questions:
- Would newer, state-of-the-art equipment improve throughput and thus eliminate the need for additional procedure rooms?
- Could the daily and weekly hours of operation be extended to allow more procedures to be performed with the existing or upgraded equipment?
Note that size, ceiling height, floor-loading capacity, and power and telecommunications requirements must be considered when replacing medical equipment in existing procedure rooms.
Improve occupancy rates with more flexible inpatient nursing units. Reconsider the use of dedicated nursing units with rigid admission criteria and low occupancy. Redesignating a boutique nursing unit for use by a broader group of patients (and cross-training staff) can potentially increase the hospital’s bed capacity. If the existing nursing unit was designed with all private rooms, these could become acuity-adaptable or universal patient rooms that can be adapted for most levels of acuity by altering staffing levels and the monitoring equipment. This concept can provide additional beds for high-acuity patients, thus supplementing the intensive care unit, and reduce costly patient transfers, provide improved continuity of care, and reduce medical errors.
Identify space that is vacant or used infrequently. There may be pockets of vacant procedure rooms or administrative offices that are “owned” by specific departments but used infrequently. This often happens to procedure rooms as equipment becomes obsolete. Even nursing units may have rooms that were originally designed for inpatient beds but which have been converted to offices or used for storage over time and which now offer a cost-effective way to increase bed capacity. Likewise, staff offices may become vacant through reorganization or converted to storage rooms.
Over time, conference and group meeting rooms located within department boundaries may have been captured for exclusive control by that department, which only uses them infrequently. Implementing a centralized scheduling system that can track utilization allows meeting rooms to be used by other staff in the organization as needed, regardless of their location.
Look for opportunities for shared or multi-use space. This allows space to be used more efficiently and balances workload peaks and valleys throughout the day or week. You can start with the low-hanging fruit ― space that is not used at least 40 hours per week. The next tier includes space that is not used 24/7, which may offer opportunities for alternating space use by shift. Here are some examples:
- Designating multi-use procedure rooms that can accommodate different types of portable equipment as needed such as EKG and ultrasound machines.
- Alternating space use by shift such as using an adjacent occupational medicine clinic or same-day medical procedure unit to treat emergency department (ED) fast track patients during the evening and night shifts. ED patients could also be held in the surgery suite recovery area during the evening for observation or while waiting for an inpatient bed to become available.
- Co-locating selected procedure rooms (or installing multi-purpose equipment) so they can share the same patient intake, prep, recovery, and support space. For example, this can work with various imaging modalities, invasive cardiology and angiography, and endoscopy and surgery.
THINK OUT OF THE BOX (LITERALLY)
The traditional hospital was designed with everything embedded in the main facility. Unbundling services that don’t need to be within that hospital “box” can provide additional capacity for patient care services. For instance:
Relocate routine, high-volume outpatient services in separate facilities. These can be on-campus or off, but should feature dedicated parking and convenient access. Examples include primary care clinics, selected high-volume outpatient services, or recurring or chronic outpatient services such as rehabilitation, chemotherapy, and dialysis.
Consolidate building support services into a separate service building. This creates space for supply, processing, and distribution functions that is less expensive to construct, renovate, and maintain as operational systems, technology, and work processes change.
Consolidate services so they can be shared among multiple hospital sites. Multi-hospital health systems can develop off-site warehouses, kitchens, reference laboratories, compounding pharmacies, and other support services.
You may need to get even more creative in rethinking the conventional use of space, even if only as a temporary measure.
Relocate administrative offices for staff who are not involved in direct patient care. Again, these can be on- or off-site in less expensive and more adaptable office building space. Creating a generic administrative office suite allows the space to be reassigned in response to organizational changes, thus eliminating department turf issues and improving overall space utilization.
Lease space instead of buying or building. This alternative allows you to limit capital investment and long-term risk by leasing space off-site for administrative offices and new or expanding outpatient programs. Some healthcare organizations may choose to lease hotel conference facilities or a school auditorium for periodic in-service or community education in lieu of constructing an education center on the hospital campus.
THINK WAY OUT OF THE BOX
You may need to get even more creative in rethinking the conventional use of space, even if only as a temporary measure. Consider the possibility of:
Virtual staff offices. Most healthcare facilities have large blocks of space dedicated to administrative offices where staff hang their diplomas and display family photos. Many organizations have successfully weaned staff from these dedicated offices to multi-use or virtual workstations. Depending on the nature of their work, and the time they are present, some staff could be assigned a mobile storage cart, which can be secured in their absence and wheeled to an available office or workstation when they are on duty.
Time-share clinic space. Creating clinics where physicians lease space ― for patient reception/intake, exam rooms, offices, and support staff ― the day of week as needed reduces fixed costs and increases overall utilization of the space.
Hall beds for ED patients who have been admitted. Even though hospitals have been trying for decades to eliminate the practice of temporarily parking patients on stretchers in corridors, a study at Stony Brook University Medical Center found that no harm was caused by moving emergency patients to upper-floor hallways when they were ready for admission. The study concluded that the common practice of boarding patients who have been admitted in the ED creates an “out of sight, out of mind” situation. Once the patients are moved to the nursing unit corridors, nursing staff get a lot more creative and aggressive with workflow practices.
Other non-traditional ways of delivering patient care. The media are full of stories about the use of non-traditional settings, from drive-through flu shot clinics to walk-in clinics at retail stores and shopping malls. With the increasing use of telemedicine there are even more patient care possibilities.
One of these is a remote presence robot, which incorporates a zoom camera and sensors that allow a doctor to conduct patient exams from his or her office using a specialized joystick and interface. The wireless, mobile robot has a TV screen for a face that shows the doctor’s head and shoulders. It can move untethered, allowing the physician to freely interact with patients, family members, and hospital staff from anywhere, anytime to provide a long-distance consult.
Another possibility is remote management of critically-ill patients, which is being successfully implemented in a number of U.S. hospitals that want to improve quality of care and patient outcomes despite shortages of nurses and intensivists. Virtual intensive care unit (ICU) monitoring centers can monitor multiple ICUs at once from a remote location with real-time telepresence, including the review of clinical documentation and medical images, the monitoring of vital signs, and the use of digital stethoscopes and high-quality video cameras. Use of this type of remote patient management system allows scarce clinical staff to be more effectively leveraged 24-7 and also gives rural hospitals improved access to intensive care resources.
Of course, sharing space and using non-traditional settings to deliver patient care requires flexibility. By definition the term flexibility means adaptable or adjustable to change. In reality, achieving flexibility often requires that physicians, department managers and staff relinquish absolute control over their space and equipment for the greater good of the organization. However difficult this may be to achieve, it must be compared to the cost, time, and energy required for a major renovation or new construction project.
In reality, achieving flexibility often requires that physicians, department managers and staff relinquish absolute control over their space and equipment for the greater good of the organization.
Many healthcare organizations may find that scrutinizing the utilization of their existing space to improve its efficiency and flexibility provides increased capacity or, at a minimum, allows them to temporarily postpone a major capital project while they assess market conditions and utilization trends.
This article is an update of a previous post.