Despite all the hospital consolidations, pharmaceutical mergers and physician group acquisitions, one vital element that has a major impact on the cost of healthcare delivery has been largely overlooked by industry executives and Washington policymakers. Many hospitals need to redesign outmoded facilities to reflect changing market requirements if they expect to prosper in a cost-conscious, managed-care universe.
Within the next five to 10 years, the healthcare landscape will bear little resemblance to the industry it's been for most of this century-when the number of beds a hospital had was an indication of its vitality and financial strength. As hospitals make the transition from revenue generators to cost centers and work to improve bottom-line performance, they also can focus on empowering patients by creating an environment that's more consumer-friendly and less institutional. Hospitals need to rethink to whom the patient room belongs.
Seeking balance.Architectural and design professionals can team with hospital management to help facilities balance the cost-driven efficiencies required under a managed-care system with the qualitative needs of patients and their families. Efficiencies achieved through new design will reduce operating costs and help pay for reconstruction.
The technological advances that have made it possible for 60% of surgeries to be done on an outpatient basis will require diagnostic and treatment spaces as well as operating rooms and recovery beds within close proximity, even though patients will stay no more than a day. Under managed care, which encourages outpatient surgery whenever practical as a way to contain costs, the ratios of outpatient visits to inpatient admissions have risen to about 60 to 1 from 5 to 1. Clearly, this has created a large surplus of inpatient beds, with the need expected to drop from a norm of four beds per 1,000 patients to 1.25 beds per 1,000 by the end of the decade.
As a result, entire hospital wings need to be re-engineered to house more ambulatory-care facilities, including the specialized diagnostic clinics, rehabilitation clinics and senior centers needed to cope with growing demand.
Cook County Hospital in Chicago is a good example. The public facility is responding to the needs of a high-risk, inner-city population by proposing to increase its outpatient services within the hospital and throughout the community while reducing its inpatient capacity significantly. Services at ambulatory-care centers will speak to important issues within the community, such as teen-age pregnancy, kidney dialysis and AIDS treatment.
Changing needs.Special requirements in a managed-care environment will be significantly less than under the current traditional care model. For example, by using actuarial data on insured patients, designers can assess healthcare space needs in a more appropriate way. Major savings will be seen in reduced acute-care areas, which can bring the space down from 7.2 square feet per patient under non-system care to 2.9 square feet under managed care. A coordinated approach to ambulatory care also can create more efficient configurations.
Most of the general acute-care beds that remain in a reconfigured hospital after reassigning the excess space will be dedicated to intensive-care or other monitored acute-care patients. As a result, multibed units will be replaced by larger patient rooms with fiber-optic capabilities and plenty of space to house diagnostic and monitoring equipment as well as patients' families.
Computerized patient records and tracking systems will permit more efficient staffing in the single-room model with clusters of small nursing stations responsible for "pods" of four to eight beds for even 1-to-1 nursing per bed. Staff also will be able to log on to computer terminals to monitor the vital signs of patients discharged to home care. Some of the groupings can be part of a larger nursing unit that could be dedicated to specific types of medical problems.
Staying flexible.The flexibility of private rooms far outweighs the costs involved because the number of beds can be 15% to 20% less than in multibed-room hospitals. Rooms must be designed with comfort and privacy in mind, with opportunities for family members to visit as well as partner in the care of the patient, conduct business during the day and even to stay overnight if necessary. Hospitals that want to stay competitive have to provide an edge to win valuable managed-care contracts.
In the 1994 Healthcare Design Awards competition, sponsored by MODERN HEALTHCARE and the American Institute of Architects' Academy of Architecture for Health, flexibility was the jurors' primary focus. Winners were recognized for designs that permitted their facilities to "adapt to organizational and structural changes in the future." Flexibility will continue to be a key component of the new healthcare delivery system as the industry responds to changing market demands.
While the cost of capital to finance redesign has increased, to resist change and maintain the status quo will sound the death knell for many hospitals. To make a successful transition to the new order, hospitals need to thoroughly research the demographics of the markets they serve and identify trends that would affect service delivery down the road. They must evaluate their facilities in light of a new profile of healthcare delivery and either rebuild or restructure to become operationally the most efficient in the market.
By using space more efficiently, anticipating and exploiting technological advances, offering a broader range of services, and developing a more patient-centered approach to care, hospitals can weather the massive changes that are occurring throughout the healthcare industry and compete effectively in the managed-care environment.