Hurricane Harvey Shows the Danger of Not Planning for Healthcare Resilience

In the Absence of Government Leadership, Healthcare Providers Must Take the Initiative to Secure Their Patients’ Health

August 31, 2017

Partner, NBBJ

Editor’s Note: Portions of this post previously appeared on Modern Healthcare.

President Obama’s Executive Order 13690 — signed in 2015 — made it the official policy of the U.S. government to improve the resilience of communities against the impact of flooding. This included special requirements for federally-funded healthcare projects, including adding three feet to base flood elevation when building federally-funded hospital facilities in flood-prone areas. But it also extended to other types of projects, including assisted living facilities and even power generation facilities.

Unfortunately, President Trump revoked this policy on August 15, 2017 — ten days before Hurricane Harvey made landfall near Houston, Texas, and shut down at least 21 of the region’s hospitals.

Growing research that shows climate change will cause hurricanes of greater intensity, as well as increased risk for flooding, in coastal communities across the United States. In a flood event, every foot counts. Building three feet above flood elevation — as required by President Obama’s regulations — could mean the difference between full hospital functionality and a complete failure of electrical, plumbing and mechanical systems.

Take, for example, Hurricane Katrina. Flooding during that disaster closed more than half of the region’s hospitals — and all of the hospitals within New Orleans itself — immediately after the hurricane. Over a decade later, some of those facilities remain closed. We saw a similar event after Hurricane Sandy in New York City, which damaged numerous hospitals, including five which remained closed a month after the disaster hit.

Even after these storms — which combined killed at least 1,400 people and caused $183 billion in damage — there are relatively few formal protections in place to safeguard healthcare facilities from storms. We believe the solution to creating more resilient healthcare facilities requires a partnership between healthcare institutions, government agencies and professionals in the building industry. We understand that additional regulations are not always the right answer. But we are concerned with President Trump’s decision to revoke the executive order without adding any protections or considerations in their place.

My firm worked on two major hospital replacement projects in New Orleans after Hurricane Katrina. There, we instituted an “upside-down hospital” design strategy which placed critical infrastructure typically relegated to the basement high above flood stage, in some cases seven floors up. At University Medical Center in New Orleans for example, the first “mission critical” floor is located 21 feet above base flood elevation.

While it’s possible the rollback of President Obama’s regulations will save money in the short term, it will likely cost healthcare systems more in the long run. A study by the National Institute of Building Sciences found that every $1 of public funds spent on disaster mitigation saves society $4. LSU’s Hurricane Center also found that stronger building codes related to wind damage before Katrina would have saved $8 billion alone. It is generally cheaper to retool infrastructure before a disaster hits.

One bright spot: only projects with Federal involvement were covered by President Obama’s executive order — and by President Trump’s rescindment of it. We continue to work with private healthcare institutions, particularly on the Eastern Seaboard, who understand the stakes and are willing to make the necessary investments. And even Federal projects, with client approval, are permitted to exceed the current requirements — but they are no longer required to, and therein lies the danger.

Healthcare systems in the United States face a myriad of challenges, including increased operating costs, switching to a value-based reimbursement model, an uncertain political environment and rapidly advancing technologies. So it’s understandable that hardening against climate-caused disasters may fall to the bottom of the priority list. But we’ve seen what can happen when that is the case.

Image courtesy of Pixabay.

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Five Priorities for Healthcare Design and Consulting

Lessons from a Clinician at the Intersection of Healthcare Delivery and Healthcare Design

July 13, 2017

Healthcare Consultant, NBBJ

Editor’s Note: This post was originally published as part of the Healthcare Design series “Take 5,” which asks leading healthcare design professionals, firms, and owners to tell us what’s got their attention and share some ideas on the subject.

1. Design firms should have nurse leaders on their healthcare teams.

When they augment their inherent clinical expertise with design knowledge, nurse leaders can be especially useful to architects and medical planners in validating design assumptions about healthcare delivery. Furthermore, their experience in marketing, writing, presenting, critical thinking, performance improvement, and personnel management enhances project performance and client deliverables. Consistent with the hallmarks of healthcare professionals, nurses are fundamentally caring individuals, possess palpable integrity, demonstrate respect for all, and have a quest for excellence through a commitment to personal growth and life-long learning. Honestly, what more could a healthcare design team ask for!

2. Satisfy the staff and you’ll satisfy the patients.

Design that focuses on the needs of care providers will benefit patients more than design that solely focuses on consumer amenities. This point was powerfully expressed to me recently by an acute rehabilitation hospital CEO, who relayed the feedback she got from patients involved in user groups during the design of their replacement hospital: they said, “Give the staff what they need, so that they can give us what we need.” She elaborated: “Those in need of rehab know firsthand it is the work of the therapists, researchers, doctors and nurses that get them to a state of ability and independence.” She made the point that a major component of patient satisfaction springs from satisfaction with the care experience and the care providers who create that experience. Therefore, take care of the staff’s design requirements too, and they will take care of the patients’ needs.

3. Address the full spectrum of safety.

All healthcare organizations aspire to an error-free culture of safety as part of a relentless pursuit of continuous quality improvement. Great progress has been made over the last few decades, but healthcare providers are still challenged by nosocomial infections, medication administration mistakes, work-related staff injuries, patient falls, incorrect diagnoses – the list goes on. The list of potential solutions is endless as well: strategies such as creating standard processes, mitigating distractions, establishing performance expectations, and requiring additional training and education. But one often overlooked answer is design. Some don’t even realize the range of opportunity for improvement made possible through the built environment. For instance, even the layout of a patient room can decrease errors, increase hand-washing and reduce fall rates; adjacencies can decrease travel time and supply utilization; decentralized work stations can increase patient engagement. As designers and nurse leaders, we should be more effective in communicating these benefits!

4. Technology integration can’t be an afterthought.

New healthcare designs always include a vision for advanced technology – indeed, it is often required to optimize the environment. Although this opportunity shouldn’t be passed up, it creates an extraordinary demand on the enterprise during the transition to the new setting. The information systems department is particularly pressured to have the prerequisite IT integration plan in place and functioning in time for a building’s opening. As well, there is a huge knowledge transfer requirement that affects all user departments, not to mention the department(s) responsible for educating them. Technology is a project requirement whose success or failure has a direct effect on the most important components of the client’s business: patient care and finances. It is an area that must be well thought out from the beginning.

5. Design intent is one thing – activating that design is a whole different story.

It is a thrilling time when a project is in the construction administration phase and materializing before everyone’s eyes. However, it is also the most critical and complex time, as the organization must plan to occupy and activate the new setting. It requires an extraordinary amount of effort and expertise to transition and activate the building safely and on time. Not only must new spaces and systems be fully operational, but staff must be comfortable with the space and a new way of doing business. It requires a remarkable amount of logistical coordination that cannot be underestimated or left to chance. Thankfully, many healthcare organizations seek expert assistance and advice during this time, and designers would do well to encourage them to continue to do so. Ultimately it is the design and the designer that will be assigned the blame if the activation doesn’t go well. Conversely, they will be ones to receive accolades if the activation goes smoothly and safely – with their design performing as perfectly as it was intended.

Image courtesy of Sean Airhart/NBBJ.

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How Will The Senate’s American Health Care Act (AHCA) Bill Affect Hospitals and Health Systems?

Despite Uncertainty in Healthcare Policy, Some Strategies Remain Unchanged

June 23, 2017

Healthcare Strategist, NBBJ

@dbellef

Editor’s Note: This post has been updated to reflect the name of the Senate bill.

On June 22, Senate Republicans released their version of the American Health Care Act (AHCA), the Better Care Reconciliation Act (BCRA), a proposal to repeal and replace Obamacare. While it has differences in timing and method from the House bill, it maintains core Republican tenets of states’ rights and freedom of choice.

 

What does the Senate bill do?

Whatever final version of the Republican repeal-and-replace legislation emerges from conference, it will almost certainly:

  • Give states much greater latitude in designing their Medicaid programs and individual commercial insurance markets.
  • Put more choice and purchasing power into the customer-patient’s hands, including the option not to purchase health insurance at all.
  • Not add net new dollars into the system, even with the “puts and takes” of tax credits, subsidies and the restoration of disproportionate share hospital (DSH) payments.

And if that isn’t enough, other transitions are already underway:

  • Medicare continues to change how it pays for care, using a variety of methods: bundled payments, accountable care organizations and more.
  • Commercial insurers, in response to their customers, continue to develop a variety of different products to lower the cost to employers, which inevitably passes higher cost on to the customer-patient.

 

What doesn’t the Senate bill do?

It does not address the continuing rise in the cost to produce and deliver healthcare. Whether Republicare, Medicare or commercial care, everyone is just reshuffling how the payer pays — and hopefully reducing the amount. Obamacare was the exception: it put more money into the system but still did nothing to control the rise in cost.

But payers don’t provide care, nor can they control cost. This leaves it in the hands of care providers to figure out new ways of producing and delivering care, as all payers — from individuals, to insurers, to the Federal government — reduce the amount they are willing to pay. It cannot be overstated: no matter what Congress does, over time there will be less third-party money coming into the system, and the customer-patient will be expected to pay more and more out of pocket.

 

What now?

Because this trend will continue independent of healthcare policy, our advice hasn’t changed. Hospitals and health systems should continue to:

  • Form more partnerships with community organizations and others who have deep interests in improving community health.
  • Accelerate the development of lower-cost ambulatory and digital healthcare offerings. We are moving inexorably toward a future where healthcare is highly distributed, in the community, the home and the person.
  • Seek greater operational efficiency. Efficiency and quality go together, and we must raise the bar on both. Technologies and systems now exist in healthcare that can do this, and they should be applied to hospital and ambulatory care alike.

Regardless of whether the Senate proposal passes in its current form, in an altered form or not at all, hospitals and health systems need to accelerate their transition to becoming providers of highly reliable care that is high in quality, is error-free and provides the results it intends to provide. This is what will lower the cost of producing and delivering healthcare for us all.

 

Image courtesy of Benjamin Benschneider/NBBJ.

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