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Getting it right the first time: A process-driven facility design approach at Virtua Health

By Tejas Ganhhi and Anjali Joseph, PHD, EDAC, Healthcare Design Magazine
April 2011

Virtua Health's $325-million replacement hospital in Voorhees, New Jersey, is planned to be a state-of-the-art, 368-bed, 669,000-square-foot inpatient facility. Future inpatient growth is expected to accommodate 600 beds and a total of 1 million square feet. The expansion will be constructed in multiple phases. The goal of providing a sensitive healing environment will be met through the use of natural elements, intuitive wayfinding, and technology. Internal circulation takes advantage of exterior views through expansive windows, visually connecting the buildings to create a campus feel. Exterior gardens offer dining areas, walking paths, and meditation areas. Each entry drive is highly landscaped to provide patients with a moment of decompression before entering.

Virtua Health used a process driven approach from the earliest stages of its hospital design to achieve the organization's goals for the project. This involved a strong focus on determining the care delivery processes that it wanted to provide and then designing the physical facility to support those processes. One of the primary goals for the design of the Virtua Voorhees facility was to increase clinician time at the bedside. This was based on research literature that suggests adverse events in healthcare could be significantly reduced by increasing clinician time at the bedside. The care delivery processes and the facility design then evolved from this and other project guiding principles.

The design process involved significant due diligence and the use of tools such as Lean to understand what was wanted in the facility. The Virtua Voorhees hospital will admit its first patients at the end of May 2011. Thereafter, the hospital intends to evaluate the impact of its redesigned processes and facility design on a range of patient and staff outcomes.

Meanwhile, even before opening, Virtua is beginning to reap some of the benefits of its rigorous process-based design approach. For instance, Virtua has been able to significantly reduce its number of clinical flow change orders. While a typical healthcare construction project of this size incurs clinical flow change order costs in the range of 3-5% of project costs (usually built into the total project costs), the change order cost for Virtua was only 0.35% of total project costs and 0.5% of total construction costs. Clinical flow change orders typically occur when the hospital owner decides to make changes that impact the design significantly. Often, the change orders occur when the clinical flow processes are determined retroactively, after the design work has been completed. In order to fit the processes into the new facility, design changes are then required, resulting in clinical flow change orders. These changes then require the design to be reworked as well as any construction that had already taken place. The construction management team usually anticipates this cost and builds it into the total project costs.

Given the pressure on hospital construction and operation budgets, healthcare organizations are focused on reducing waste and improving efficiency with existing resources. Virtua's experience indicates that minimizing clinical flow change orders is one way to reduce waste in the hospital construction process.

How was the hospital able to achieve this?

Getting the right people on board
The Virtua team involved staff members across the organization, experts, and consultants early in the process to obtain the necessary input into its new facility design. Virtua also became a member of The Center for Health Design's Pebble Project so it could learn from peers nationally and internationally.

A charge to "design around process" required a nontraditional approach to planning.

Getting it right the first time
Virtua invested heavily in doing its due diligence prior to the start of the design process so it was able to develop a strong vision for what it wanted in the new facility. Virtua has distinguished itself as one of the first Six Sigma and Lean organizations in healthcare. A charge to "design around process" required a nontraditional approach to planning. Working in collaboration with GE Healthcare and Lean and Six Sigma experts from Virtua, their internal HGA industrial engineering and medical planning Lean team created a unique process for the planning and design of its Greenfield campus.

Due diligence.
Some key steps were undertaken early on in the design process to enable the team to visualize its ideal future state.
  • Multidisciplinary user groups used a research-based process with an emphasis on optimal clinical pathways, patient and family experience, and leveraging of technology.
  • Photo journaling was used to capture the experiences of patients, family, and staff, identifying major themes and space needs for the new facility.
  • The operations leadership was asked several big questions ranging from volume projections, outpatient/inpatient demographics, supply chain sourcing, technology adoption, and care models to throughput performance measures.
  • After reviewing industry journals and best practices, the operational leaders researched future-state operating models and defined anticipated future process. Direction for space planning, defining critical adjacencies, and early consensus was achieved through this effort.
  • Site visits were undertaken to gain confidence when faced with ideas requiring significant changes in current practice. Site visits provided 18 HEALTHCARE DESIGN 04.11 external insight and perspective for consideration in the planning process.
  • Technology roadmaps were developed to define the path for each program that would propel their technological adaptation to the desired position in 10 years. Information derived from the roadmaps gave insight into future care delivery, which defines future patient and clinician flows.
  • Current state operations were mapped, identifying opportunities in design to better support people and process with space. Spaghetti diagrams and Lean principles were used for evaluation and comparisons.
  • Unencumbered by the current facility, users were asked to create the ideal flow, considering the voice of the customer and key performance metrics.

A structured design process. The design process followed a structured approach to understanding the strengths and weaknesses of different schemes. Virtua's guiding principles formed the basis for evaluating these different design schemes and better understanding the benefits of each one. The innovative design process included the following methods:
  • Extreme schemes;
  • Force ranking;
  • Developing the hybrid; and
  • Rapid prototyping.

Extreme schemes - As part of the master planning development, six extreme options were developed, each providing a distinctive attitude about dedication, separation, site, entry wayfinding, branding, land use, views, natural light, staff and patient travel distances, and operational efficiency. Force ranking - Force ranking provides an objective way of evaluating the extreme options. Developing the hybrid - The hybrid incorporated the strengths of the top-performing extreme schemes, resulting in three performance centers in one - a women's and pediatric tower, a general adult tower, and an outpatient destination, separate from the hospital functions. Rapid prototyping - The ideas were put to test quickly through rapid prototyping. Mock episodes of care were run to test the "future" physical spaces, asking:
  • "Where does the design fail?"
  • "How will technology change the way we work?"
  • "How does it promote our goals?"
  • "How will it affect our metrics?"

Leadership and accountability
Strong leadership was one of the key factors responsible for keeping the project on track and true to its vision and goals. During any design project, there are multiple competing priorities and often there are requests for modifications to the design to accommodate the needs of individuals and groups within the hospital team. The framework of the guiding principles, the structure of the process-based approach, as well as the Lean tools at the team's disposal provided what was needed to make strong decisions and to stick to those decisions. As a result, there were few situations requiring design changes or clinical flow change orders.

What was the impact of the savings on the Virtua project?
During the course of the project, the Virtua team realized it was at risk of exceeding the allocated budget. As a result, the team undertook a value engineering process. Some design elements were removed from the project at that point with the intent of possibly buying them back further down the road. As a result of the cost savings realized from reduced clinical flow change orders, the team was able to make the decision to divert those savings toward projects on its wish list. For example, Virtua has been able to furnish its eighth operating room, a project that had originally been shelved. Also, a nursing floor that also was not to be furnished until a later date will now be complete at the time of opening.

What's next for Virtua?
The new Virtua Voorhees facility opens in May 2011. The six to nine months after opening will be crucial as the staff settles into the new facility and gets used to the new processes as well as physical design changes. A strong focus on improved outcomes - increased clinician time at the bedside, increased patient satisfaction, increased employee satisfaction, and improved patient safety outcomes - has been an inherent part of the process driven approach for Virtua. Lean tools such as simulation were used to forecast outcomes associated with this design project, and these simulated outcomes will be compared to actual outcomes in the new facility. This will help Virtua evaluate its design process as well as the impact of the implemented design strategies and processes.

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