Nilay Deshmukh Associate AIA, LEED AP

1
Ila Minnick MS, RN, CNOR Director of Surgical
Services Wm. S. Middleton Jr. VA Hospital ,
Madison , WI (T) 608-256-1901 X 17374 (e)
Ila.Minnick_at_va.gov
Nilay Deshmukh Associate AIA, LEED AP Shepley
Bulfinch Richardson and Abbott 2 Seaport Lane,
Boston, MA 02210 (T) 857 383 4355, 617 423 1700
(e) ndeshmukh_at_sbra.com

2
Research Statement
Many Surgical Services, hailed as
state-of-the-art 10-15 years ago are becoming
functionally obsolete long before their physical
life is spent. . .
How do we ensure that Healthcare Facilities are a
sustainable resource for the rapidly changing and
unknown future?
When could healthcare buildings be considered
disposable? 15 years for equipment and
hardware? 50 year life span for buildings to meet
the changing needs of the future?
3
Forces Impacting Healthcare Facilities

• Population Dynamics and Demographic Patterns
• Socioeconomic Factors
• Disease Trends
• Changing Workforce
• Changes to Healthcare Delivery Systems
• Philosophical Changes to Practice of Medicine
• Innovations
• Changing Techniques
• Changing Technology

4
Population Dynamics
Aging of America

• By 2010 1 in 4 Americans will be 65
• 75 million baby boomers are retiring
• Morbidity falling by 1 -1.5 / year
• Life expectancy has reached 77.8

5
Population Dynamics
Aging of America

• Patients with increased acuity and more complex
  problems
• Focus on geriatric diseases
• Informed and demanding customers
• Will boost consumer market
• Seek alternate medicine/ treatment

6
Population Dynamics
Immigration/ Diversity

• 1 in 4 Americans is of a race other than
  Caucasian
• 1 in 3 by 2050
• Medical errors Language/ Communication
• Integration of family

7
Socioeconomic
Rising Number of Uninsured

• 16 have no health insurance
• Insurance premiums jumped 59 since 2001
• Employer-based premiums rose by 9.2 in 2005
• Resulting in. . .
• Burden of charity care
• Postponement of care
• Increased patient acuity

8
Socioeconomic
Healthcare Costs

• Low reimbursements
• Federal State budgets are overwhelmed
• Hospital charity care is being challenged
• Hospitals are losing money or operating at very
  low margins
• 73 rise in hospital spending is expected
  between 2000 to 2010

9
Socioeconomic
Healthcare Costs

• Hospitals are being forced to add/improve their
  facilities
• Under massive push for cost reduction
• Using borrowed money
• Under tight budgets
• Under tight schedules

10
Disease Trends/ Threats
Disease Trends

• Complex/ Chronic multi-organ diseases
• Diseases related to Obesity
• Diseases like cancer will become chronic

• Needing. . .
• Ability for rapid diagnosis of complex Issues
• Imaging, screening diagnostic services
• Labs and molecular medicine
• Infrastructure to handle geriatric bariatric
  population

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Disease Trends/ Threats
Threats

• Pathogens are jumping from animals to humans
• Mutant antibiotic resistant strains
• Infectious diseases Avian flu, SAARS
• Bioterrorism, Superbugs

• Need. . .
• Appropriate Care Services Surge Capacity for
  ED, ICU etc.
• Ability to treat infectious patients
• Capacity to handle a large number of patients
• Digital information transfer

12
Workforce
Shortage of Healthcare Providers

• Average age of RN is gt 43 years
• Will average 50 years by 2010
• Shortage of Physicians, Physical Therapists,
  Pharmacists, and Radiology Techs etc. continues
• Complex care vs. increased work loads

• Need. . . physical work environment that
• Supports the aging workforce
• Decrease physical demands
• Decrease risk of injuries

13
Healthcare Delivery Systems
Philosophical Changes to Practice of Medicine

• Growing emphasis on elimination of disease
  rather than cure
• Increased demand for evidence-based medical care
  
• Increased accountability for medical errors
• Ethical/ social dilemma over the disclosure of
  patient information

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Healthcare Delivery Systems
Innovations

• Genomics
• Could eliminate need for treatment altogether
• Xenographs - genetically engineered organs and
  tissue
• Pharmacology
• Smart Drugs targets cancer like smart bombs
• Nutraceuticals mixtures of vitamins, nutrients
  and synthesized chemicals
• New vaccines

15
Healthcare Delivery Systems
Innovations

• Nanotechnology
• Miniscule artificially intelligent machines
• Nanomachines designed to do specific tasks
• Nano-Biology
• Injectable agents from DNA sequence will search
  for disease producing agents and neutralize them
• Chemoembolization
• Uterine Fibroid Embolization
• Focused Ultrasound

16
Healthcare Delivery Systems
Changing Techniques

• Anesthesia
• Lower Levels of Sedation
• Shorter Duration
• Greater Patient Monitoring
• Surgical Techniques
• Smaller Incisions
• Noninvasive/ Less Invasive
• Shorter Case Length
• Postoperative Recovery
• Lower Risk of Complications

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Healthcare Delivery Systems
Implications Philosophical Changes to Practice
of Medicine

• Consumers will seek to prevent diseases/
  maintain good health
• Elimination of many diseases
• Accelerated healing process
• Medicine will replace complex procedures
• Increase in Noninvasive Techniques
• Competition with freestanding facilities will
  continue
• High-Risk Patients will come to the hospitals
• Increase in utilization of CT, MRI imaging
• Technology driven diagnosis

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Healthcare Delivery Systems
Changing Technology

• Telemedicine
• Medicalbots / Cyberdocs
• Access to care 24 hours a day
• Decentralization
• Robotic techniques to operate remotely
• Data can be transferred anywhere
• eICUs - virtual patient monitoring
• Chronically ill patients can be equipped with
  intelligence-enhanced nurse-bots for 24 hour
  duty

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Healthcare Delivery Systems
Changing Technology

• Less need for patients to drive to the hospitals
• Supporting facilities need not to be in the
  hospital
• Home health care will become more efficient
• Use of technology to deliver health care anytime
  anywhere
• Confluence of image data-basing, computing
  power, electronic storage, electronic commerce

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In Summary
21
Near Future

• Hospitals are under pressure to build
• Tight budgets, tight schedules (rising costs)
• Consumer market, Competition of freestanding
  facilities
• Patients with increased acuity and more complex
  problems
• Rise in geriatric bariatric population
• More patients - fewer care providers,
• More technology - fewer technicians
• Complex procedures will shift to outpatient as
  interventional
• Miniature Instruments, Small Incisions, Lower
  Sedations
• Shorter Case Lengths, Shorter Prep and Recovery
• Increase in Imaging based techniques/ procedures

22
Distant Future

• Medicine will replace complex procedures
• Elimination of many diseases
• Care from remote locations
• Less need to drive to hospitals
• Rise in homecare networks
• Technology
• Would become faster
• Less demanding on space, construction, and
  design
• Life expectancy may continue to increase,
  maximum life span may not

23
Near Future
Would the Surgical Services be on expansion mode
in near future (for the next 10-12 years)?
Bigger the Better?

• Would the trend continue longer?
• Is science over-promising?
• Genetic reformatting might be very expensive as
  a personal solution
• 50 of practicing physicians never took a course
  in genomics
• Many diseases are on the rise without any
  logical explanation

24
Near Future
Demand for Surgical Services

• 100 billion- 47 increase on new facilities in
  last 5 years
• 16 billion in 2004
• gt 20 billion/year increase till 2010 when it
  will level out

25
Distant Future
Would Diagnostic and Treatment Services switch to
contraction or reorganization mode (after 12-15
years)?
Search for Variable Dynamic Solutions?
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Distant Future
Demand for Surgical Services
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How do we ensure that Healthcare Facilities are a
sustainable resource for the rapidly changing and
unknown future?
Facilities that can Expand or Shrink - as needed
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Dynamic Systems

• Envision healthcare facility as a Dynamic System
  through,
• Strategic Planning
• Master Programming Master Planning
• Functional Programming Design
• Construction Documents and Construction
  Administration
• Post-occupancy Phases

The challenge is to anticipate where changes are
most likely to happen and apply dynamic approach
through all stages.
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Strategic Planning (Vision)

• Define long-term goals
• Anticipate shifts/ growth areas
• Recognize long range demands and pressures
• Evaluate if current trends create opportunities
  or barriers?
• Heart Hospitals, Children Hospitals
• Fluid and Changeable Plan
• Should be periodically revised/ adjusted

Long Term
Sherman Hospital
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Master Programming Planning
Single Building vs. Healthcare Campus

• Campus
• Allows for Progressive Development
• Selectively Renew, Replace Expand Individual
  Elements
• Operationally Less Disruptive

Dartmouth Hitchcock Medical Center
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Master Programming Planning
Single Building vs. Healthcare Campus
Example Dartmouth Hitchcock Medical Center
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Master Programming Planning
Single Building vs. Healthcare Campus

• Single Building
• Large Floor Plates
• Limited Ability to Rearrange Easily/
  Economically
• Domino Effect

33
Master Programming Planning
What to Consider?

• Plan for Phased Development
• System components and municipal services should
  not have to relocate
• Place D T services on outside wall next to
  soft spaces
• Plan for Swing opportunities and changes to use

1st Floor
Sherman Hospital
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Master Programming Planning
What to Consider?

• Plan for Phased Development
• System components and municipal services should
  not have to relocate
• Place D T services on outside wall next to
  soft spaces
• Plan for Swing opportunities and changes to use

ED
ICU
ORs
MOB
Cath Labs
Prep/ Recov.
2nd Floor
Beds
Sherman Hospital
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Functional Programming Design

• Key Considerations
• Pattern of Utilization/ Hours of Operation
• Capacity Surge Capacity
• Impact of Technology
• Multidisciplinary Departments/ Integration
• Changing Workforce/ Multi-skilled Staff
• Dynamic Modules
• Future Capacity
• Changing Space needs

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Functional Programming Design
Example Pattern of Utilization/ Hours of
Operation
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Functional Programming Design
Impact of Technology
Years X Faster X Smaller X Lighter
60 600 6,000 60,000
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Functional Programming Design
Spilling Over of Technology
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Functional Programming Design
Spilling Over of Technology

• Many procedures are similar to interventional
  radiology
• Increasing reliance on image guidance
• Redefinition of Sterile Field - Surgery-like
  Environment

40
Functional Programming Design
Spilling Over of Technology
41
Functional Programming Design
Spilling Over of Technology

• Image Guidance Magnetic Navigation
• Intra-operative MRI, PET-MRI
• Stationary, Pivoting Couch, Traveling Magnet

Intra-operative MR-OR, Childrens Hospital Boston
42
Functional Programming Design
Spilling Over of Technology
Surgery
Cancer Treatment
Radiology
ED
43
Functional Programming Design
Spilling Over of Technology

• What's Coming. . .
• Conversion of. . .
• Operating suite to Cath Labs. .
• Cath Labs to MRA or CTA. . .
• Sterile Field is getting redefined

44
Functional Programming Design
Multidisciplinary Integration
Same Floor Model
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Functional Programming Design
Multidisciplinary Integration

• Same Unit Convergence Model
• Interventional Convergence

Do not plan in detail for future technology but
identify technology zones for future
46
Functional Programming Design
Multidisciplinary Integration
Same Room Convergence Model

• ORs with Control Rooms
• Ability to accommodate a range of needs
• Interventional
• Surgical
• Procedural
• Avoids reconstruction

47
Functional Programming Design
Impatient- Outpatient Dilemma
Hospital vs. Ambulatory Centers
Second Floor Plan La Clinica, Universidad de
los Andes
Separate service within the hospital/ on campus

• Combined Model
• Separation of flow
• Shared Services

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Functional Programming Design
Generic Approach Dynamic Modules
How to expand or reorganize?
49
Functional Programming Design
Generic Approach Dynamic Modules

• If interventional volume declines, can the rooms
  be adapted?
• Allows reallocation of programs within the space

50
Functional Programming Design
Generic Approach Dynamic Modules
CLEAN CORE
Second Floor Plan Sherman Replacement Hospital
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Functional Programming Design
Soft Spaces/ Future Capacity

• How much future capacity?
• Could avoid future domino effect
• Upfront investment
• Could lead to increased program space

52
Functional Programming Design
Changing Space Needs

• Physical demands of technologies
• Rising need for storage
• HIPAA - Patient Privacy
• Fixed as against movable equipment (C-arm,
  Ultrasound)

53
Functional Programming Design
Impact of Technology

• Volume
• MR based and CT based scans would take minutes
  rather than hours
• MSCT 4-6 times faster than CTs More use
  faster throughput
• Space Requirements
• 3.0T MRI fields are larger than 1.5T MRI fields
  but not twice the size
• Integrated Practice of Medicine
• Converging Modalities
• Example Angiography would not be necessary with
  Multislice CTs
• Turf battles Competition among surgeons,
  interventional radiologists and cardiologists
  will continue

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Functional Programming Design
What can designers do?

• Clear, Easily Extendable Circulation
• Generic Approach
• Reallocation of programs with minor alterations
• Standardization of Sizes (modified or
  reassigned)
• Moment-resistant steel frames instead of braced
  frames
• Provide Adaptable Infrastructure
• Floor systems
• Ability to allow penetrations for service
  changes for future
• Incorporate a systematic redundancy

55
Functional Programming Design
What can designers do?

• Materials not restrictive for changes due to use
  of space
• Changes to materials that are disruptive, noisy,
  dusty costly
• Consistent materials for maintenance, repair and
  change
• Ceiling systems that allow access for
  maintenance change

• Rigid mechanical core vs. mobile, portable, and/
  or modular
• Multiple HVAC systems
• Small zones that can be easily changed and
  upgraded

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CD, CA and Post-Occupancy Phases
Planning for Change

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CD, CA and Post-Occupancy Phases
Project Delivery Methods - Problem Solving
Approach

• Designers should lead integrated project
  delivery methods
• Teamwork- Integration of disciplines
• No solution, Problem solving process
• Be prepared for changes
• Understand potential needs beyond the timeline
  of the project
• Building a room for one vendors system,
  regardless of modality, does not mean the room
  will be adequate for another vendors equipment

58
CD, CA and Post-Occupancy Phases
Project Delivery Methods - Problem Solving
Approach
Traditional Blame-Game Model
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Conclusion
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Conclusion

• Needs for aging and sicker population will
  define the short term future
• Emphasis on elimination of disease than cure
  would have a significant long-term impact
• Innovation and technology will accelerated the
  dynamism
• Designers would have to design spaces that can
  expand or shrink - as needed
• Spaces that could quickly, economically, and
  repeatedly retrofitted reconfigured
• Adopt dynamic approach on all levels

61
Questions?
Ila Minnick MS, RN, CNOR Director of Surgical
Services Wm. S. Middleton Jr. VA Hospital ,
Madison , WI (T) 608-256-1901 X 17374 (e)
Ila.Minnick_at_va.gov
Nilay Deshmukh Associate AIA, LEED AP Shepley
Bulfinch Richardson and Abbott 2 Seaport Lane,
Boston, MA 02210 (T) 857 383 4355, 617 423 1700
(e) ndeshmukh_at_sbra.com