Want to Build a New Ambulatory Surgery Center?

Six Items to Consider Before You Start to Build Your Next ASC

January 27, 2020

Partner, NBBJ

Editor’s Note: This post was coauthored by Mackenzie Skene and Hao Duong. It was originally published in Becker’s ASC Review.

Ambulatory Surgery Centers (ASCs) promise to offer high-value services in a cost-effective environment. This is leading to tremendous growth, with the latest figures showing more than 50 percent of all surgeries in 2017 were performed in ASCs, compared to 32 percent in 2005. Organizations looking to capitalize on this trend by building new ASCs can do so, yielding expanded access, greater convenience and improved efficiency.

However, these benefits can only be achieved through careful analysis and preparation. Six ideas healthcare systems should consider:

  1. Improving access. 
    Bringing surgical services from the hospital campus to other communities may disconnect the ASC from ancillary support services. Consider what ancillary services are provided locally or served from the hospital. For example, centralizing sterile processing and pharmacy at the hospital may reduce costs, simplify staffing and maintain quality control standards. However, this may come at the cost of increased transportation demands, insufficient instrument and equipment availability, and an inability for staff to react to immediate needs. Recruiting and block timing can also be a challenge, as surgeon preference and access to outpatient clinical spaces for pre- and postoperative visits may be limited. This may result in patients bouncing between different facilities for everything from perioperative examinations to medications and durable medical equipment. Consider the thresholds that would trigger building redundant systems at the start of a project.
  2. Cost considerations. 
    Because ambulatory patients are typically healthier and undergo less complex surgeries than other populations, infrastructure requirements and room sizes are significantly less for an ASC. Even escaping the robust seismic and life-safety requirements of an I-2 hospital construction type can result in cost savings when compared to the cost of constructing a hospital surgery suite. But don’t expect all these savings if the ASC is expected to support more complex procedures. Building codes are slowly adapting to the trend where procedures historically performed in a hospital are moving to outpatient settings; and a certifying body can require the ASC to meet the standards of an inpatient surgery suite. Add in the high cost of construction and redundant staffing for local sterile processing and pharmacy, and the result can easily tip the cost scales. Consider whether accommodating more complex procedures erases the cost benefits of building an ASC.
  3. The 23:59 rule. 
    CMS states procedures requiring more than 24 hours (from intake through recovery) are not candidates for ASCs. As technology permits the execution of more complex cases in an ambulatory setting, organizations should consider providing additional provisions to patients who can go home within 24 hours but may want more time on site for education and physical transition. Some states already allow for extended recoveries, while others require that any such accommodation be distinct from the ASC and not offer direct medical care. ASCs considering this approach should talk to their local certifying body to work through the many details, ranging from clinical staffing to food services.
  4. Flexibility is key. 
    Designing a single-specialty ASC can maximize efficiency and reduce the need for extraneous storage, equipment variation and general overbuilding. However, this approach comes at the compromise of future flexibility, as elements not accommodated on day one may be cost-prohibitive to add later. Also, if an organization desires to lock in the future flexibility to perform many different procedure types by including them under their license or certificate of need, a certifying body may limit or revoke that license if the design only supports a subspecialty. Consider whether procedural flexibility is likely needed in the near future or just nice to have, and whether those components can be accommodated in other ways — like with a building that can be expanded.
  5. Building beyond essentials. 
    One appealing aspect of an ASC is the ability to build only what is essential. Operating room sizes can be reduced, perioperative spaces can be built for limited hours of service and infrastructure does not need to be as robust. With increased competition in the marketplace, though, an ASC should consider providing amenities for both the patient and caregiver. Adding a café can be good for families and staff, electrical outlets in furniture can keep people connected and comfortable beds to sleep on — not just a stretcher — can differentiate ASCs. Even a well-done integrated ceiling system in the OR can improve aesthetics and promote a cleaner environment. Consider what features might differentiate your ASC and attract more customers.
  6. Planning for emergencies. 
    Working with healthier patients does not mean procedures always go according to plan. As more complex cases are performed in the outpatient setting, relying on 911 for emergency situations may prove insufficient. A nurse call system may be necessary to augment communication among staff, and training a team to stabilize a patient while waiting for help may also be needed. Moreover, an ASC may find itself informally or formally designated as the default center for an individual or public health emergency due to proximity. Consider the difference between what is required versus what is likely to happen in the ASC, especially in rural areas.

The cost of constructing and operating an ASC depends on many factors. So, as an organization settles on the type and scope of a new ASC, a comprehensive analysis should be performed to confirm that this new project will provide the care patients deserve, and either increase revenue and lower costs, or alternatively move volumes from the main campus to another location.

Banner image courtesy Sean Airhart/NBBJ.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX

To Get to Net Zero, Cities Need to Think Wider Than Buildings

Cities Have to Embrace District-Wide Net Zero Solutions to Create Change at a Scale That Will Make a Difference

January 15, 2020

Partner, NBBJ

Editor’s Note: This post was originally published on Smart Cities Dive.

The city of Boston has recently made headlines for an ambitious new plan that mandates all new city-owned buildings to be carbon neutral, part of a wider plan for the city to achieve net zero status by 2050. The attention on this announcement and the framing of net zero makes sense — finally, there is a sustainability goal for the city that people could fully grasp and get behind, a readily understandable and appealing arithmetic proposition that the city’s buildings will eventually produce as much energy as they use.

The challenge, of course, isn’t in getting people excited about the prospect of going net zero — fervor around the term has grown with the number of buildings that meet the standard. The challenge is preparing cities for what it’s going to take to actually make net zero a realistic possibility.

An ambitious goal like Boston’s requires a total overhaul in how we think about sustainability, at every level of impact. The changes must go beyond recycling, using LED light bulbs, and even constructing net zero buildings, since individual buildings or projects can only go so far. Cities will have to embrace bigger, district-wide or neighborhood-scaled solutions that create change at a scale that will make a difference.

The city already has a good model for district energy looks like in practice with the Kendall Station power plant in Cambridge [PDF]. For years waste heat was dumped from the cooling processes of the plant’s generating turbines into the Charles River basin. The resultant overheated river water produced large algae blooms, making the river waters toxic to not only wildlife but also humans who came in contact with the algae. By virtue of a mutual agreement, today waste steam heat from the power plant is piped across the Charles River to Massachusetts General Hospital in Boston, where it is used for heating the campus in the winter and to sterilize equipment year-round. The proximity of a large hospital physical plant, which had the unusual need for steam 12 months of the year, to the power plant was a fortuitous urban condition and demonstrated the beauty of thinking about district-wide solutions for achieving net zero.

Examples like this demonstrate how we need to change the way we think and talk about sustainability. As an architect and city planner, I’ve seen time and time again how the way we communicate an idea is a powerful tool for helping people feel like they can tackle daunting problems. It’s also true that rhetoric can have the opposite effect. Solutions at the scale of the city tend to be complex. They don’t carry the catchy recognition of a well-marketed phrase like “net zero,” but they do make it possible for net zero to be a feasible goal.

I learned this firsthand during my time on the Getting to Net Zero Task Force in Cambridge. In 2015, the Cambridge City Council approved the Net Zero Action Plan, a 25-year proposal that will get Cambridge to net zero by 2040 — the result isn’t just talk but real policy, embodied in the city‘s net zero zoning. To make this work, we understood that the definition of net zero needed to be expanded. Solutions come in myriad form, including accessing green energy from out of state. After all, creating a market for non-CO2-producing energy sources outside the boundaries of one’s own city helps the planet at large. In Cambridge these offsets absolutely count towards netting out a building’s carbon footprint. So daisy-chaining energy production in neighborhoods, and yes, designing homes and buildings with an eye to energy savings so it is ultimately easier to net out the energy use with clean production need to be strategies too.

Approaching sustainability as a set of steps and achievable benchmarks can take away some of the daunting magnitude of the task at hand. In Cambridge, for instance, the city started by putting its money where its mouth was. The city is requiring all government buildings — firehouses, police stations and schools, for example — to be net zero by 2025. Next, we’ll tackle the biggest, most energy-sucking buildings — laboratories — with the goal of getting them to net zero by 2030.

But that doesn’t mean it’s impossible. In Seattle, for example, Amazon’s new downtown headquarters captures waste heat from a non-Amazon-owned data center on an adjacent block to reduce their own energy consumption. It’s just one company, and an area of only a few blocks, but it’s an important proof-of-concept that points the way forward. On an even larger scale, the United States Department of Energy has launched a Zero Energy Districts Accelerator program that is currently piloting projects in Denver, St. Paul, Buffalo, Huntington Beach and Fresno.

Designers and architects are well positioned to push net zero forward. The job is to imagine futures that don’t exist today, to generate creative solutions that speak to all of the above-mentioned scales. District-wide solutions to energy prove that, if we work together, even more powerful and kaleidoscopic solutions are possible for our mind-boggling and seemingly impossible environmental challenges. The solutions to climate change can be remarkably beautiful and may even lie in some pretty old-fashioned values, like building strong communities, relying on our neighbors and believing that design matters.

Banner image courtesy Nelson48/Wikipedia.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX

Four Factors Driving Healthcare Interior Design

How to Ensure Healthcare Interiors Contribute to a Healing Environment

January 6, 2020

Architect, NBBJ

Editor’s Note: This post was co-authored by Kerianne Graham and Edwin Beltran. It was originally published in Building Operating Management.

In healthcare, interior design has moved beyond just materials to consider elements like wayfinding, biophilia, natural light, and more. Even more important, however, is to think about how those elements combine to create a healing experience for patients, visitors, and staff. That experience is driven most by four factors — people, process, place, and technology — all of which have an impact on interior design.

At the Palo Alto Medical Foundation San Carlos Center, drought-resistant plants suited for the California climate reduce the need for artificial irrigation while connecting with people’s innate love for nature.

 

1. People

An outstanding experience is one that uniquely responds to the physical, cognitive, and emotional needs of the diverse population of users who experience a space, which, in a healthcare environment, typically means patients, family, and staff. Healthcare environments should address those needs in a way that is supportive, enabling, inspiring, and dignifying.

One way for interior design to improve the experience for patients and their families is to reduce the anxiety of the unknown. First impressions matter. An appropriate space of arrival, like an atrium or lobby, that considers the needs of key populations, can help people feel welcome and navigate clearly. For instance, at the new replacement hospital for the Southeastern Louisiana Veterans Health Care System, research showed that many Louisiana Veteran patients would be traveling great distances to the hospital, so the designers located necessary amenities like bathrooms prominently near the front door.

Arrival spaces can extend beyond the lobby, too. In the Lunder Building at Massachusetts General Hospital, a sixth-floor atrium welcomes patients and visitors to the patient floors with comfortable furniture, abundant daylight, and plantings.

Spaces like this also help patients and their families establish a positive routine, especially for those, like oncology patients, who may visit the hospital frequently. Welcoming, easy-to-find areas like the café, chapel, and garden space can help to shift a person’s focus away from treatment.

And don’t forget about staff. Studies show that caregiver satisfaction is directly correlated to patient recovery times, so ensuring the physical and mental wellbeing of the care team translates directly into improved medical outcomes. One solution, simple in concept but difficult in execution, is to bring daylight deep into the “backstage” areas of a hospital, such as patient-floor corridors or even the sterile clinical zones where caregivers spend much of their day.

Private staff space is also important, especially for behavioral health providers, social workers, and case managers — really, anyone who might deliver bad news or work with critical patients — who may often need to recenter themselves after a stressful situation. And because staff are more likely to use spaces that are out of view of patients and families, it is critical to provide separate, more private places of respite. These spaces can resemble “mothers’ rooms,” with comfortable movable furniture, soft materials, a calming color palette, and dimmable lighting. They can also be outdoor, landscaped spaces which rely on nature to provide a sense of calm, as at the new Big Lots Pavilion for behavioral health at Nationwide Children’s Hospital.

What’s more, the caregiver experience can be improved by connecting staff — and their patients — to the organization’s mission of care. Nationwide Children’s accomplishes this with brand standards that employ video throughout the hospital depicting staff talking about their experiences, their passions, and their purpose.

 

2. Process

While process improvements aren’t often considered an interior design issue, every process change has a design implication. Every provider seeks an efficient care model that supports business goals and positive patient outcomes, but those processes must always focus on creating an outstanding, personalized experience for patients and their families.

Consider the waiting experience. Typically patients sit in the waiting room, staring at the door where nurses emerge, waiting for their name to be called, getting more and more anxious. Simply reconfiguring the seating so patients aren’t staring at the door can make a big difference. While many institutions are working to reduce typical wait times, patients still need places to rest between the stages of their visit, and families will still experience waiting if they’re not accompanying the patient to the treatment space.

For even greater impact, consider activity-based waiting. Like activity-based workplaces, this means giving people options: the option to socialize, to work, or to retreat in private. This can be achieved with different types and groupings of furniture, with a range of spaces from quiet to active, and with access to food and drink. Waiting time doesn’t have to be wasted time — waiting time can allow people to be productive, educated, entertained, or simply together.

Providing options also transforms a patient’s experience of his or her room and creates a sense of normalcy. Like the waiting area, patient rooms can be designed to support a variety of modes, from rest, to socialization, to work, to meals and more. A recent patient room concept, inspired by micro-apartment design, aimed to do just that, with fold-down tables and retractable sleeping platforms so patients and families can work, socialize over a meal, or visit overnight.

Some of these concepts made it into the design of the Fetal Care Center at Nicklaus Children’s Hospital, where the millwork in labor and delivery rooms includes an integrated fold-down table, so new a mother can enjoy breakfast the next day with her newborn and her partner. Other recent projects are installing mini-fridges and microwaves so patients can save food for when they’re ready to eat, or so their families can bring homemade meals to share in the hospital.

Even when integrated furniture isn’t possible for spatial or budgetary reasons, flexibility can also be provided with moveable furniture so visitors can reconfigure the room to look at the patient, the physician, or even just out the window.

 

3. Place 

An outstanding experience is created by leveraging the physical qualities of an environment to project a distinctive identity that embodies and reflects the aspirational qualities of your brand. It is a place that visually communicates your mission, culture, and values while spatially promoting, supporting, and enabling the behaviors and actions associated with those broader goals.

Interior design can also put patients at ease by connecting them to the place where they live and by giving them a sense of belonging, either with architecture that evokes the vernacular traditions of an area, or with design elements that reference local history and culture. Throughout University Medical Center in New Orleans, for instance, custom design touches pay homage to the ornamentation and rich heritage of New Orleans, from environmental graphics with historic motifs and city scenes, to the large courtyards that reference the vernacular architecture of courtyard homes in the French Quarter. These features help patients not only feel at home, but also navigate the large campus.

Another recent example is the expansion of Swedish Medical Center in Edmonds, Wash. Here, design features celebrate Edmonds’ logging heritage, with 250-year-old boom logs that greet visitors in the lobby and salvaged wood integrated into the landscapes. The architecture also references the region’s glacial past, with striated metal panels that evoke geological strata.

Landscape is another essential element of place. Native plantings take biophilia to the next level, by connecting not only with humans’ innate love for nature in general, but for their love of the everyday natural world in which they live. It is also inherently sustainable — at the Palo Alto Medical Foundation San Carlos Center, for example, drought-resistant plants suited for the California climate reduce the need for artificial irrigation.

 

4. Technology

Finally, the healthcare experience — like so many other things — is being transformed by technology. Technology enables people to become more active participants in their own care, and those who do so are likely to have improved health behaviors, positive care outcomes, and enjoyable care experiences. Simple engagement tools such as personal tablets and self check-in kiosks are already well-established in many settings, but the opportunities for deploying technology throughout the care experience are expanding rapidly.

One important role of technology is to strengthen communication between patients and caregivers. This can be accomplished with telemedicine — remote consultations with care providers — patient tracking systems, patient portals, and, in the not-too-distant future, medical-grade wearable devices. Telehealth systems can also improve communications between caregivers themselves, especially among distributed care teams.

Another important goal is transparency and information sharing, to ease patients’ anxiety by keeping them informed about where they are in the process. As artificial intelligence becomes more sophisticated at understanding our daily patterns, it can be used to remind people of their upcoming medical appointments. Virtual concierges can be used to check people in remotely and guide them to their hospital destination. Real-time location systems can the track patients throughout their healthcare journey, much like airplane check-in apps that text travelers updates on their flight status.

Real-time location systems also make it possible to reduce the size of waiting rooms and convert that space to variable, flexible environments that take activity-based waiting to a whole new level, providing freedom and choice for patients and staff. Thanks to technology, waiting doesn’t even have to be in the hospital at all — waiting can happen anywhere, and patients can receive the same level of service they’ve come to expect.

Real-time location systems apply to supplies as well, making it possible to implement just-in-time inventory, which reduces the amount of space needed on patient floors for storage. What can that space become? The possibilities for improving the experience for patients and staff are almost limitless.

Not all technological advancements may affect interior design directly, but they will affect operations, and as operations change, they will free up new opportunities for design.

 

On Beauty 

Neuroscience research has shown that the human brain reacts to beauty — that is, to spaces in which form, proportion, volume, light, materiality, landscape, and other sensory aspects are balanced and working in tandem. Our attention changes in environments that are diverse and dynamic and surprising. Around things it perceives as beautiful, the brain calms, and stress — measured in cortisol levels — decreases. Most people cannot explain why they react the way they do, but they definitely perceive it.

To cite just one example, the landscape at the Neuroscience Center at Riverside Methodist Hospital in Columbus, Ohio, is designed to store stormwater runoff while enhancing the lobby experience and campus grounds. Water flows from the roof into a series of illuminated, architectural concrete weirs, then into a basin where it is retained and filtered by wetland plants — selected for scale, texture, seasonal color, and ease of maintenance — before passing into the campus’ drainage system. The resulting landscape is beautiful, functional and — judging by the visitors who crowd the lobby windows during storms to watch it in action — even dramatic.

What’s more, beauty should be democratic. When people are in beautiful spaces, they feel better about themselves. Beauty shapes a person’s entire experience, and nowhere is this more important than in healthcare. By considering the people you’re designing for, the processes and behaviors you want to encourage, the unique qualities of the places where people live and work, and the ways in which technology can advance not only medical care but also the human experience, we can create truly transformative healthcare environments that help people live and work their best.

Banner image courtesy Bruce Damonte/NBBJ.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX
Next Page »

Follow nbbX