Sometimes the best facility plan leads to no new facilities.

by Mike Boguszewski, Healthcare Planning Associates

Some years ago, I was touring outpatient multi-specialty ortho and rehab building that had just been completed on the campus of a major academic medical center.  Practices had opened for business the previous Monday - this was a Friday - and already the sounds of renovation air hammers and screwdrivers could be heard screeching through the halls.  When I asked the head nurse what was going on, she replied, "Oh, well they built the door to the imaging room too narrow to get stretchers into."  (This was in an orthopedics building, remember.)  "What do you mean, too narrow?" I pressed.  "Here I'll show you.", and walking over to where the workmen were noisily toiling away, she pointed out, "the door isn't wide enough for the stretchers to turn into as they come around this corner here.  So they're widening the door".  As someone not always able to resist a little subtle sarcasm now and then, I perkily said, "Gee, you're right - the door entry does seem to be not in quite the right place relative to the corner, especially for a room where almost everyone going in will be on a stretcher."  To which the nurse shrugged, and replied with words emblazoned in my brain forever:  "Well, what're you gonna do - you won't know until you build it!"

Bzzzzz!  Wrong answer.  So often in my career I've seen projects completed, and more importantly started, without anyone having taken the time to consider and document exactly what the project is all about in the first place.  What is the facility supposed to accomplish?  What is its purpose - and not just "purpose" as in "a place to house such and such department" - but a grander sense of purpose:  in terms of organizational strategy and tactics, what will be this building's role?

In the case of the orthopedics clinic, it was something as "small" as the role of the imaging room that had been given short shrift.  If anyone on the architectural team had simply stopped to ask, "Hey, what's going to be happening in this spot, how will the patients get here and out again?", then a little operational foresight would have avoided thousands in hurried catch-up remodeling.

The sad truth is this lack of fore planning is not limited to this small of a scale.  There was the major hospital in Florida that quickly built a new "Heart Surgery Pavilion" in order to cash in on the boom in cardiac procedures a number of years ago - only to get the thing open just in time to see all those dollars move over into cath programs, and then scramble to find a way to get some ROI on all those nice, huge, multi-million-dollar cardiac ORs. 

Or the internationally-regarded academic medical center (AMC) that first let the contract for architects to start designing a magnificent new ambulatory center because the current one was so squeezed, and THEN asked, hey, how well are we actually utilizing what we have now?  And THEN considered, is this the highest priority to spend our capital on right now?  And THEN began to think that maybe someone should actually test that assumption that such new, efficient space would pay for itself.

The fundamental error with these examples is that hospital leadership began the problem-solving process with the solution:  build a building.  What must be kept in mind is that the facility is never the solution.

Now, as a facility planner, how can I make such a bold (and perhaps business-dampening) declaration?  Because I know that a building - a mess of reconstituted stone and brick and mortar and glass and metals and whatnot - a building is really just a place in which to do something.  And I further know that usually the problems rest in how the things are being done, NOT in the shell that surrounds them.  At best, a new facility may be one of the tools that helps resolve those problems.

Let's start with what is typically the big issue: capacity.  You have run out of space.  Period. Or have you?  Have all the operational "expansions" been looked at?  Not just tactical stuff like longer hours, better scheduling, and so on - but strategic options:  is it time to look at "bubbling out" some activity into satellite or neighborhood locations?  Is it time to work on growing volumes that will make a new building "full" at opening, rather than think "build it and they will come" and then lose your entire margin as you pay for all that new space for no more revenue than you made last year?  Is it time to actually restrict capacity for some programs or services, so focus can shift to ones with higher clinical priority, or a needed better payer mix?  Example:  a nice, new big Emergency Room will never be calm on "knife and gun club" night, because you will never be willing to say to that next patient at the threshold, "Sorry, we've reached our optimum treatment room utilization for the evening".  So your new wider hallways will still be teeming, and by the way, you'll also have tipped the balance of beds in your ICU to "mission driven" medical patients in lieu of those nice surgical ones with which you'd hoped to fill it.

The point is, if you're going to go out and drop a couple hundred million into bricks and mortar, you'd better be sure your ducks are in a row, because at some point, whether a nosy Board member or one of the inquisitive minds of the local press (who care so deeply about the taxpayers), someone will demand to see proof that all those dollars were justified.

Good facility planning is always strategic.  This is true whether for one identifiable process, (e.g., emergency care; ortho outpatient clinical encounters), or for mega-scale operations, (e.g., inpatient services; ambulatory specialty and sub-specialty care).  The first questions should revolve around examining what is dysfunctional about current operations, and what can be done to fix it.  If the dysfunction is clearly and exclusively tied to deficiencies in the space that houses those activities, then maybe you actually have a "facilities project".  In my own practice, a phone call from a prospective hospital or physician group client may begin, "Say, we need help planning a new building."  As strange as it may seem, my first job is to challenge that.  Why do you need it?  How do you know?  What do you need this building to do for you?  What role will it provide within your overall enterprise that nothing else can provide today?

The architect's job is to ask:  when do you want to start to build?  The planner's job is to ask:  why do you want to start to build?  And the hospital's job is to keep in mind that a building is just another tool to help you achieve your strategic and operational goals - it is never the goal in itself.  Sometimes the best strategic facility plan is to build no new facilities at all.

Mike Boguszewski can be reached via www.healthcareplanningassociates.com