11

Rural Hospital Summer Rural Hospital Summer WorkshopWorkshop

June 24, 2008June 24, 2008

Construction Projects: Construction Projects: Strategy to Strategy to

Implementation Implementation

Health Facilities Planning & Development

22

Jody CaronaJody Carona Health Facilities Planning and Health Facilities Planning and

DevelopmentDevelopment

Joe KunkelJoe Kunkel The Healthcare Collaborative GroupThe Healthcare Collaborative Group

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Setting the Stage… Setting the Stage… Creating the Vision Creating the Vision

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"I saw an angel in the stone, and I carved to set it free"

-Michelangelo

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First Things First: Strategic/Master First Things First: Strategic/Master Planning Creates the VisionPlanning Creates the Vision

SP Process: Quantification of – SP Process: Quantification of – Community need and demand-inpatient Community need and demand-inpatient

and outpatient and outpatient Market positionMarket position Medical staff Medical staff Community perceptionsCommunity perceptions Physical plant needs versus current Physical plant needs versus current

physical plant—major space drivers physical plant—major space drivers (beds, (beds, ED, ORs, etc.) ED, ORs, etc.)

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Visioning Is Also ImportantVisioning Is Also Important

May also require revisiting of vision and May also require revisiting of vision and mission statements. mission statements.

77

Understanding Your Community’s Understanding Your Community’s Need and DemandNeed and Demand

What is the size of the market? What is the size of the market? How do you define your primary service area?How do you define your primary service area? Who else serves this market? Who else serves this market? How many admissions annually?How many admissions annually? How many ED visits, surgeries etc?How many ED visits, surgeries etc? How are demographics changing? What How are demographics changing? What

impact will this have on future need and impact will this have on future need and demand? demand?

88

99

RegulatoryPressures

Reimbursement

DebtCapacity

Safety &Security

TechnologyAdvances

StaffShortages

EmpoweredPhysicians

OperatingMarginPressure

Consumerism

Demographics

Drivers ofChange

Times Are “A-Changing”Times Are “A-Changing”

1010

Demographics are a Major Driver of Demographics are a Major Driver of Future VolumeFuture Volume

Understanding demographics is key… Understanding demographics is key… Elderly use services at 2.5 times the rate of Elderly use services at 2.5 times the rate of

under 65.under 65. What assumptions do we want to make What assumptions do we want to make

about the future role of the hospital— about the future role of the hospital— service delivery, etc.?service delivery, etc.?

1111

Drill Down as Far as Possible….Drill Down as Far as Possible….

The ‘Typical’ Rural AreaThe ‘Typical’ Rural Area

20052005 %% (WA St)(WA St) 20102010 ChangeChange

Tot. Pop.Tot. Pop. 10,06110,061    10,16710,167 + 1%+ 1%

0-170-17 1,9941,994 20%20% 24%24% 1,8521,852 - 7%- 7%

Fem. 15-44Fem. 15-44 1,7111,711 17%17% 21%21% 1,7181,718 + 0%+ 0%

65 +65 + 1,8751,875 19%19% 12%12% 2,0432,043 + 9%+ 9%

Lower % of peds and OB Lower % of peds and OB womenwomen

Slow, steady growth overallFlat growth for peds and OB women

Rapid growth for seniorsHigher % of seniors

1212

Inpatient Market Position is Easy to Inpatient Market Position is Easy to Quantify Quantify

Inpatient:Inpatient: CHARS allows us to easily quantify size of CHARS allows us to easily quantify size of

inpatient market—by zip code of residence, inpatient market—by zip code of residence, patient age, DRG, and hospital/MD.patient age, DRG, and hospital/MD.• Can track changes in utilization and market share Can track changes in utilization and market share

over time.over time.• This data is key to projecting future inpatient bed This data is key to projecting future inpatient bed

needs. needs.

1313

Inpatient Market DataInpatient Market Data

Service LineService Line

20042004Avg. Avg. Annual Annual Chg. in Chg. in DaysDays1996-1996-20032003

Market Share of 2004 DaysMarket Share of 2004 Days

Disch.Disch. DaysDays ADCADC The The HospitalHospital

Hospital Hospital AA

HospitaHospital Bl B

HospitaHospital Cl C

Other Other HospitalHospital

ssTotalTotal

CardiologyCardiology 618618 1,5961,596 44 -1.67%-1.67% 28.5%28.5% 23.4%23.4% 18.4%18.4% 0.7%0.7% 29.0%29.0% 100.0100.0%%

General General MedicinMedicinee

785785 1,9001,900 55 1.39%1.39% 39.7%39.7% 22.4%22.4% 15.3%15.3% 3.3%3.3% 19.3%19.3% 100.0100.0%%

General General SurgerySurgery 352352 2,2252,225 66 1.00%1.00% 17.1%17.1% 8.9%8.9% 3.8%3.8% 6.2%6.2% 64.0%64.0% 100.0100.0

%%

OB/DeliveryOB/Delivery 326326 1,1071,107 33 2.55%2.55% 61.6%61.6% 22.8%22.8% 0.0%0.0% 0.5%0.5% 15.1%15.1% 100.0100.0%%

OrthopedicsOrthopedics 608608 2,0252,025 66 -0.81%-0.81% 24.4%24.4% 10.4%10.4% 2.0%2.0% 9.3%9.3% 54.0%54.0% 100.0100.0%%

OtherOther 225225 526526 11 0.36%0.36% 15.3%15.3% 9.6%9.6% 3.5%3.5% 2.4%2.4% 69.4%69.4% 100.0100.0%%

TOTALTOTAL 2,9142,914 9,3799,379 2626 0.52%0.52% 25.5%25.5% 13.8%13.8% 7.8%7.8% 4.5%4.5% 48.5%48.5% 100.0100.0%%

1414

But, We Continue to Struggle with But, We Continue to Struggle with the Ever Increasing Outpatient the Ever Increasing Outpatient

MarketMarket

OutpatientOutpatient Historically, much more difficult to quantify—Historically, much more difficult to quantify—

but “proxies” are possible via community but “proxies” are possible via community surveying and/or Solucient outpatient data. surveying and/or Solucient outpatient data.

Changes in outpatient as much a function of Changes in outpatient as much a function of technology and reimbursement as technology and reimbursement as demographics.demographics.

1515

Understanding Medical Staff Need Understanding Medical Staff Need and Current Situation is Also Key and Current Situation is Also Key

Should first compare community need for MD Should first compare community need for MD against supply. Are there unmet needs and against supply. Are there unmet needs and realistic opportunities?realistic opportunities?

Must also include existing MDs in process:Must also include existing MDs in process: Are they committed to staying in the community? For Are they committed to staying in the community? For

how long? how long?

Is there a need for a formal medical staff Is there a need for a formal medical staff development process. How much $$ will this development process. How much $$ will this require? require?

1616

Surveys are Often a Good Way to Surveys are Often a Good Way to Collect the Needed InformationCollect the Needed Information

Key Survey QuestionsKey Survey Questions Practice Data (visits, % at the Hospital, payer Practice Data (visits, % at the Hospital, payer

mix, etc.)mix, etc.) Practicing In/ Recruiting to the CommunityPracticing In/ Recruiting to the Community Perceived Manpower/Recruiting NeedsPerceived Manpower/Recruiting Needs The Hospital’s Role in RecruitingThe Hospital’s Role in Recruiting Specific Perceptions of the HospitalSpecific Perceptions of the Hospital

1717

Calculations of Need Should Calculations of Need Should Consider: Consider:

20102010 Avg. Pop.Avg. Pop. Net Phys.Net Phys.

to Phys.to Phys. Avg. Phys.Avg. Phys. Need: AgeNeed: Age

PhysicianPhysician Age Adj.Age Adj. Age Adj.Age Adj. Current Current Adj.-Current Adj.-Current

SpecialistSpecialist Ratio: 1 to-Ratio: 1 to- NeedNeed SupplySupply SupplySupply

Family/General Family/General PracticePractice 3,085 3,085

Internal MedicineInternal Medicine 4,452 4,452

PediatricsPediatrics 8,987 8,987

All Primary CareAll Primary Care - -

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How Does the Community Perceive How Does the Community Perceive the Hospital? Will they Support the Hospital? Will they Support

Growth and Development?Growth and Development?

Strongly consider a community survey Strongly consider a community survey and a series of key informant interviews.and a series of key informant interviews.

1919

How Does the Community Perceive How Does the Community Perceive the Hospital?the Hospital?

Community survey-will address issues of:Community survey-will address issues of: Utilization and patient satisfaction:Utilization and patient satisfaction:

Primary care practitionersPrimary care practitioners Specific outpatient services Specific outpatient services Inpatient servicesInpatient services Urgent careUrgent care SpecialistsSpecialists

Reasons for leaving the communityReasons for leaving the community Awareness/perceptions of HospitalAwareness/perceptions of Hospital Priorities for local health carePriorities for local health care Demographic info (insurance, etc.)Demographic info (insurance, etc.) Willingness to taxWillingness to tax Other issues as appropriateOther issues as appropriate

2020

How Does the Community Perceive How Does the Community Perceive the Hospital?the Hospital?

Key Informant Interviews:Key Informant Interviews: Perceptions of hospital, hospital leadershipPerceptions of hospital, hospital leadership Role of hospital in the communityRole of hospital in the community Other divergent/convergent issues facing Other divergent/convergent issues facing

the communitythe community Future vision for the hospitalFuture vision for the hospital

2121

The End Result….The End Result….

Clear goals and direction.Clear goals and direction. Clear delineation of space needs at Clear delineation of space needs at

varying market share assumptions.varying market share assumptions. Must take the next step of comparing Must take the next step of comparing

existing plant to projected needs.existing plant to projected needs.

2222

Demographics

Gross Volumes

SpecificVolumes

Operating P&LSpace & CapitalRequirements

Financial Model Logic Flow

FILTERS:-Clinical-Volume-Market Share-MD Availability/Supply-Support-Financial

Drivers:-Population Projections-Age/Gender-Utilization History

2323

From Strategy to From Strategy to Implementation Implementation

2424

Major Facilities DirectionsMajor Facilities Directions

Replacement Major Expansion Minor Expansion

Existing Facility Existing Faculty

Major Expansion

New

NewNew

New Replacement

Existing Facility

High CostLong DurationLarger System wide Strategic Decision

High CostMedium Duration

Lower CostShorter Duration

New

1 2 3

2525

Environment

Market Analysis and Plan

Operational Design

Physician Develop

PatientExperience

FinancialPlan

Technology

Hospital Expansion/ Renovation

Plan

Vision & Strategy

2626

Getting OrganizedGetting Organized

2727

Project Structure Chart

CMO COO VP ITVP HREquipment Planner THCG VP MARKETINGPROPERTY MANAGER

Hospital Leadership

Physician Leaders

Architect

THCG

VP HRVP IT

Equipment PlannerProperty ManagerMission Services

CEOVP

CMOCOOCFO

VP Support ServicesVP Marketing

HospitalSTEERING COMMITTEE

VisionBaseline AssumptionsPolicyStrategyImageBudget

STAFFInternal Project Lead

WORKING GROUPS

Report to Steering Committee

User Group Leadership& Communication

Operational Concepts & Philosophies

Physician Development

OPS Planning Design

EquipmentPlanning

HumanResources

InformationTechnology

ProjectDevelopment

CommunityRelations &

CommunicationMOB

Physician Need Analysis

Recruitment Strategy

Medical StaffDev’t/Priviledging/Credentialing

Establish Adjacencies& Flow

Department Design

Room by room equipment planning

Procurement Strategy

Overall staffing strategy

Training

Leadership Development

Overall IT Strategy

Telecom, Voice/Data

Low Voltage

Access Control

Clinical Applications

Day to day managementof construction process

Public Approvals

Design Control

Budget/Schedule

Q/C

Developer Selection

MOB Development

Leasing

Internal Communication

External PR/Image

Community Health/Mission Integration

Fundraising

USER GROUPSLOCAL JURISDICTIONDesign ReviewBuilding DepartmentFire Marshall

STATEDOH

MOBDeveloperPhysicians

HOSPITALDx & TxEmergencyInpatient ImagingOutpatient ImagingCardiac CathLabSurgeryPT/OTRehab TherapyResp Therapy

SUPPORTCentral SterilePharmacyMat. Mgmt/Recycle/DocHousekeepingAdmittingPre-Admission TestingMedical RecordsGift ShopChapelPublic SpacesHospitality/ValetAdministrationDietaryConf/Med Ed/Library

PATIENT BEDSMed/SurgICUStep DownShort StayPACUPrep/Hold

OTHERPlant/EngineeringSecurityIT/TelecomParkingInfection Control

Space & Equipment NeedsRoom DetailsRoom Function & ConfigurationOperationsCurrent/Future Needs

Hospital Leadership

Physician Leaders

Architect

THCG

Hospital Leadership

Physician Leaders

Architect

THCG

Hospital Leadership

Physician Leaders

Architect

THCG

Hospital Leadership

Physician Leaders

Architect

THCG

Hospital Leadership

Physician Leaders

Architect

Contractor

Hospital Leadership

Physician Leaders

Architect

THCG

Hospital Leadership

Physician Leaders

Architect

THCG

2828

Visioning Visioning

Different than Strategic VisionDifferent than Strategic Vision Set Guiding Principles for ProjectSet Guiding Principles for Project

Overarching common attributesOverarching common attributes• SafetySafety• Flexibility v. expandabilityFlexibility v. expandability• EfficientEfficient• HealingHealing• Recruitment/retentionRecruitment/retention

2929

VisioningVisioning

Set MetricsSet Metrics Measurable goalsMeasurable goals Project-specificProject-specific S-t-r-e-t-c-hS-t-r-e-t-c-h Project-influenced goals as wellProject-influenced goals as well

3030

Keys to a Successful ProjectKeys to a Successful Project

Communication, Communication, Communication, Communication, CommunicationCommunication

Set of written “Working Assumptions”Set of written “Working Assumptions” Clear Decision-MakingClear Decision-Making Regular UpdatesRegular Updates

WrittenWritten PhonePhone In-personIn-person

Project Management – Project Management – Owner/Architect/ContractorOwner/Architect/Contractor

3131

Design – Getting it RightDesign – Getting it Right

3232

Prioritization of FLOW in DesignPrioritization of FLOW in Design

Objective Subjective

Patient VolumeProfitability

Strategic Importance

Growth

BrandCompetition

Physician RelationsCommunity Disruptive Tech

Staffing Intensity

3333

Design IssuesDesign Issues

Clear Space ProgramClear Space Program Master Planning – Long-TermMaster Planning – Long-Term Project Design – Short-TermProject Design – Short-Term Mock-ups and Other ToolsMock-ups and Other Tools

3434

Establishing a Project BudgetEstablishing a Project Budget

LandLand EntitlementsEntitlements ConstructionConstruction EscalationEscalation ““I” v. “B”I” v. “B” Soft CostsSoft Costs ContingenciesContingencies

3535

Land CostsLand Costs

Purchase PricePurchase Price Criteria for DevelopmentCriteria for Development Time HorizonsTime Horizons Location, Location, LocationLocation, Location, Location Infrastructure & EntitlementsInfrastructure & Entitlements TimeframesTimeframes

3636

ConstructionConstruction

Market CompsMarket Comps EscalationEscalation ““I” v. “B”I” v. “B”

CostCost FlexibilityFlexibility ReimbursementReimbursement

3737

Soft CostsSoft Costs

Cost the Same as Hard Costs!Cost the Same as Hard Costs! Design FeesDesign Fees EngineeringEngineering Project ManagementProject Management Jurisdictional FeesJurisdictional Fees

3838

Owner’s CostsOwner’s Costs

Medical Equipment (and Planning)Medical Equipment (and Planning) Furniture/Fixtures/EquipmentFurniture/Fixtures/Equipment Information TechnologyInformation Technology

CablingCabling ApplicationsApplications

ContingenciesContingencies

3939

Do the MathDo the Math How many by specialtyHow many by specialty Lead times/degree of difficultyLead times/degree of difficulty Population-based v. facility-basedPopulation-based v. facility-based ““Need” v. “redistribution”Need” v. “redistribution” Don’t be “beggars”Don’t be “beggars” Pool of potential staffPool of potential staff Open process/project structure/communicationOpen process/project structure/communication Exclusives/RFP’sExclusives/RFP’s

MD Development & MD Development & RecruitmentRecruitment

4040

Think CreativelyThink Creatively

4141

In the End……..In the End……..