Complete credit for the following article is given to author Joe Tye. Joe Tye, M.H.A., M.B.A., is the CEO of Values Coach Inc., a health care consulting and training firm in Solon, Iowa. He is also a member of Speakers Express. Cultural Transformation in Health Care Settings was published in the February 21, 2012 issue of Hospitals & Health Networks magazine.
Cultural Transformation in Health Care Settings
By Joe Tye February 21, 2012
Think like a physicist to effect change in your organization.
In The Dancing Wu Li Masters, Gary Zukav writes, "The way that we pose our questions often illusorily limits our responses … . The way we think our thoughts illusorily limits us to a perspective of either/or." My goal in this article is to use the laws of physics to help readers think in new ways about shaping the culture of their hospitals. If it's true that culture eats strategy for lunch, then a cultural plan is more important than a strategic plan. Used as a metaphor, Zukav's Wu Li Masters can help you think in new ways about cultural transformation.
But first, an important point: The laws of physics are morally neutral. The momentum of a speeding garbage truck will cause it to ram into a school bus full of children or a prison bus full of convicted killers with equal certainty. Likewise, corporate culture is morally neutral. Enron had a powerful culture, but it was a culture corrupted by greed.
That said, here are some thoughts on the laws of physics and their implications for corporate culture:
Nature abhors a vacuum. Every organization has a culture. Just as physical nature moves to fill a vacuum, so human nature creates cultural traditions, practices and expectations within organizations. The question is whether this culture is allowed to morph haphazardly, or is guided by principles and a plan that are clearly defined and well communicated.
Inertia is best overcome by engaging informal leaders. A body at rest tends to stay at rest, and absent deliberate management intervention, corporate culture becomes stale and stagnant. In an inertia-bound culture, you hear things like "We tried that and it didn't work" and "We've always done it this way." The larger the organization, the more energy it will take to begin the cultural transformation process, similar to the way it takes more energy to move a bowling ball than it does a pool ball. But, unlike pins passively awaiting the crash of a bowling ball, a hospital's leaders can strategize the most appropriate cultural response to health care reform, whatever form it eventually takes. Resorting to a top-down, command-and-control process (e.g., cutting staff with layoffs) is a Newtonian "organization-as-machine" approach; whereas, training employees on the personal skills of ingenuity, courage and resilience is more consistent with the paradoxical relationships evident in quantum physics.
Friction is inevitable and must be overcome. The first thing you encounter when you seek to overcome inertia is friction. The greater the change required, the greater is the resistance. Knowing that friction is inevitable can help you fortify yourself with the determination to forge ahead in spite of it. And just as a snowball gains mass as it overcomes friction rolling down a hill, once the transformation process begins, you will find that the skeptics of yesterday have become the champions of tomorrow.
Critical mass is essential to sustain change. To spark significant cultural change, you must have a critical mass of people buying into the desired change. Researchers suggest that about 30 percent of a population is sufficient to reach critical mass in launching a movement. So, for example, when a third of us decided we would no longer tolerate being poisoned by other people's cigarettes, the movement to ban public smoking became unstoppable. At Tri Valley Health System in Cambridge, Neb., a group of about 50 people meet every morning for several minutes to collectively recite that day's promise from The Self-Empowerment Pledge. According to CEO Roger Steinkruger, that one simple group action has had a positive impact on the hospital's culture, and it is now spreading to other parts of the community.
Escape velocity is generated by staff commitment. A spaceship headed for orbit must first attain sufficient speed to break free of Earth's gravitational pull; the greater the mass of the spaceship, the greater the speed required. To achieve cultural transformation, you need a sufficient number of people (mass) who are sufficiently galvanized (emotional velocity) to escape the inertia, pessimism, cynicism and toxic emotional negativity of the past. Fillmore County Hospital is a critical access hospital in Geneva, Neb. As part of a hospitalwide values training initiative, its leaders asked every employee to think about his or her personal values, then published a beautiful booklet with the responses. Patient satisfaction scores have improved in 27 of 30 measures, which the leaders attribute to having achieved the "cultural escape velocity" caused by a sufficient number of people making the commitment to act on those values.
Momentum assures ongoing progress. A body in motion tends to stay in motion. One of the things that struck me when researching All Hands on Deck: 8 Essential Lessons for Building a Culture of Ownership is the extent to which cultural momentum carried each of the market-dominating companies featured in the book long after charismatic founders like Walt Disney, Ray Kroc, Mary Kay Ash, Bill Hewlett and Dave Packard had departed. In the strongest organizations, cultural momentum is a powerful form of leadership. Organizational structures like Hamburger U at McDonald's ensure that cultural norms are transmitted to each new generation of future leaders.
Randomly intervening variables can foster new solutions. Natural evolution was profoundly altered when an asteroid slammed into Earth some 65 million years ago, leading to the dinosaurs' extinction. In cultural terms, outside factors including the economy, politics, competition and other variables inevitably complicate culture change. But as Margaret Wheatley points out in Leadership and the New Science, "Disequilibrium is the necessary condition for a system's growth." When a group of physicians in Kearney, Neb., announced plans to build their own hospital, leaders at nearby Good Samaritan Hospital feared the doctors would recruit nurses from their hospital. So Good Samaritan evaluated potential sources of employee dissatisfaction and took actions to enhance loyalty. Though the physicians' hospital is not yet completed, Good Samaritan built a stronger and more positive culture as a result of the challenge.
Entropy is the enemy of progress. Culture does not maintain itself; it requires constant attention. When Columbus (Ind.) Regional Hospital was inundated by a flash flood in June 2008, it appeared likely that entropy would set in. Basic services were shut down, the hospital was closed for five months, no revenue was coming in, and the hospital knew its "best places to work" culture and high-performing workforce were at risk. The executive team and board made a decision to keep everyone on the payroll for five months, at a cost in excess of $30 million — money that had been set aside for a new patient tower and emergency department. The hospital reopened with staff intact, continues to be rated as a best place to work, and enjoys a growing reputation for excellence. Its most recent national recognition was for its innovation center — a facility made possible as a result of flood-related rebuilding.
Black holes must be confronted and marginalized. Scientists recently have discovered a black hole estimated to be the mass of 21 billion stars the size of our sun. Black holes literally suck the life out of any objects that come too close. Organizations, unfortunately, have people like that — emotional vampires who suck the life out of people with whom they work and, eventually, out of organizations for whom they work. Marginalizing these human black holes is a fundamental leadership duty. (I shared 14 strategies for doing this in my previous H&HN Daily article, "A Positive Approach to Negative People.")
Quantum leaps are created by inspired leaders. One of the most surreal aspects of quantum theory is the notion that an electron can skip from one orbit to another without ever traversing the space between — the quantum leap. During the mid-1990s, under the leadership of Ken Kizer, M.D., the Veterans Health Administration made a rapid transition from widely being seen as a caregiver of last resort to an organization about which Phillip Longman could write a book credibly titled Best Care Anywhere. Today the VHA is going through a similarly radical cultural transformation to promote Veteran-centered care. Belying the notion that transforming a huge organization is like turning a battleship, the VHA has achieved substantive change at a quantum-like pace.
The problem of measurement requires new thinking. Even more than in management, with its mantra that "what gets measured gets done," physics is a science based on measurement. But there is also an acute awareness of the limitations of measurement. According to the Heisenberg uncertainty principle, the simple act of trying to measure something affects that which is being measured. A manager might believe that he or she is improving patient satisfaction by giving employees a script and a happy face pin, but the way that script is delivered can have a perverse effect. The things that most matter to patient satisfaction are notoriously difficult to measure with traditional metrics. Compassion, enthusiasm, pride and other "soft" qualities cannot be measured, but they certainly can be observed. Like physicists trying to understand the magnificent complexity of the universe, one of our challenges is finding new ways to assess those things that cannot be measured in the traditional manner.
Culture is a force field to be understood and galvanized. In physics, the concept of the force field explains how gravity, electricity and magnetism can cause two entities that are not in physical contact to have a physical effect on each other. Culture is a force field in which attitudes and behaviors in one part of the organization are transmitted across space and time via invisible forces like rumor and gossip; example and expectations; stories and traditions. And like gravity, culture is no less real for being invisible. Mapping out the vectors that transmit culture is a useful way of employing these forces to bring about desired cultural change.
Elegance defines the best work settings. When it evolves according to nature's laws, the universe tends toward elegance: From the Grand Canyon to photographs taken by the Hubble space station, there is beauty in the natural order. The same can be said for organizations that dominate "best places to work" lists: They have beautiful and functional corporate cultures. The Tao of Physics by Fritjof Capra was one of the first books to look at physics from a social sciences vantage point. Capra highlights similarities between modern quantum physics and ancient Eastern philosophical traditions, saying, "The further we penetrate [into modern physics] the more we … see the world as a system of inseparable, interacting, and ever-moving components, with man as an integral part of this system." More recently, in The Elegant Universe, Brian Greene describes how string theory almost makes the universe feel like a gigantic musical instrument. That's a beautiful metaphor for the culture of an organization known for being a best place to work and a best place in which to receive care.
Culture Can Change
There is, of course, another essential difference between the laws of physics and the principles of cultural transformation: The laws of nature are immutable while cultural practices are fluid and malleable. Nevertheless, thinking in terms of physical laws of the universe can provide a useful metaphorical tool for promoting a more positive and productive culture in your organization.
Joe Tye, M.H.A., M.B.A., is the CEO of Values Coach Inc., a health care consulting and training firm in Solon, Iowa. He is also a member of Speakers Express.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
Wednesday, February 22, 2012
Sunday, January 29, 2012
Suggested Subscription
Recommended Professional Subscription
As a holder of a Ph.D. in Health Services, it is assumed and expected that you are aware of the broad area of research that is taking place in the health care environment. As a KAM writer, you are constantly in search of "current research articles published in scholarly journals" (Depth Component). As a researcher at the doctoral level, you are expected to be aware of past, current and future research being planned or conducted in your area of specialization.
I suggest that you subscribe to:
"RESEARCH ACTIVITIES" from: Agency for Healthcare Research & Quality, US Dept. of Health & Human Services
To subscribe to "RESEARCH ACTIVITIES"
Send an email to: ahrqpubs@ahrq.hhs.gov with "Subscribe to Research Activities" in the subject line. Be sure to include your mailing address in the body of the email
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"Work Smarter ... Not Harder"
Robert E. Hoye, Ph.D., FAAMA, FRSH
Diplomate In Healthcare Administration
Faculty
Health Services
College of Health Sciences
Walden University, Minneapolis,MN
robert.hoye@waldenu.edu
502 426 6350 (Home Office)
Visit Blog: http://robertehoye@blogspot.com/
As a holder of a Ph.D. in Health Services, it is assumed and expected that you are aware of the broad area of research that is taking place in the health care environment. As a KAM writer, you are constantly in search of "current research articles published in scholarly journals" (Depth Component). As a researcher at the doctoral level, you are expected to be aware of past, current and future research being planned or conducted in your area of specialization.
I suggest that you subscribe to:
"RESEARCH ACTIVITIES" from: Agency for Healthcare Research & Quality, US Dept. of Health & Human Services
To subscribe to "RESEARCH ACTIVITIES"
Send an email to: ahrqpubs@ahrq.hhs.gov with "Subscribe to Research Activities" in the subject line. Be sure to include your mailing address in the body of the email
A
"Work Smarter ... Not Harder"
Robert E. Hoye, Ph.D., FAAMA, FRSH
Diplomate In Healthcare Administration
Faculty
Health Services
College of Health Sciences
Walden University, Minneapolis,MN
robert.hoye@waldenu.edu
502 426 6350 (Home Office)
Visit Blog: http://robertehoye@blogspot.com/
Tuesday, January 24, 2012
Better Ways of Thinking about the Future
The author ... Joe Flower is an internationally known futurist and consultant to health care executives. This represents his posting of 1/24/12 in H&HN Daily. I highly recommend this article by him to all of my students.
REH
Better Ways of Thinking about the Future
By Joe Flower January 24, 2012
How do you learn to "Think Different," as Steve Jobs' famous ads put it?
Let's think about the structure of thought for a moment. The great experimental psychologist Daniel Kahneman, in his recent book Thinking, Fast and Slow, shows how much of our thinking and decision-making is driven by illusions and assumptions, such as the "illusion of validity" (the false belief in the reliability of our own judgment), the "availability bias" (a biased judgment based on memories that are more easily available or more vivid) and the "endowment effect" (the tendency to value something more highly when we own it than when someone else owns it).
This makes sense. Kahneman's analysis resonates strongly with my experience working with executive health care teams, including providers, health plans and suppliers, and with governments in North America, Europe and China over several decades. Smart, seasoned executives can make seriously poor judgments, especially when the environment changes.
Curiously, these illusions, biases and assumptions are driven by our experiences. So, being more experienced does not necessarily exempt us from illusion, unless something in our process constantly and directly tests the results of our judgments (as, say, a robust retail market does on price setting). Even if the judgments are correct, they are based on an environment: in the jungle or the savanna, in a controlled market or a retail market, in a risk-bearing business arrangement or an endowed business arrangement. When our environment shifts, the illusions and biases and assumptions persist, even though they may be dangerously out of date.
We are in a rapidly shifting environment. Over the next several years, all health care leaders will be called on to make numerous strategic decisions and tactical choices that fundamentally will be different from decisions they are used to making. But they will be making those decisions with a mental apparatus formed in the old environment.
A Thought Exercise
How do we rethink our assumptions? How do we approach the unfolding situation with a continually fresh mind?
Here is a basic and enormously useful thought exercise. Take some time to write down a number of basic facts and beliefs about your organization, anything from facts such as "We own XYZ Home Care" to opinions such as "Tom's a lousy communicator." Then take one of these "truths" and find several ways to form an opposite of it.
An opposite of "We own XYZ Home Care" could be "We don't own XYZ Home Care," "Our crosstown rivals own XYZ Home Care," "XYZ Home Care owns us," or "We keep XYZ Home Care's assets, but farm out the management," or even "The business we now think of as 'home care' disappears and becomes something else," for instance.
The opposite of the opinion "Tom's a lousy communicator" could be "Tom's a great communicator," "I'm a lousy listener to Tom," or "There's really no need for Tom to be a great communicator."
Entertain one or another of these opposite assumptions for a while. Treat it as if it were true. Assume that, in some way, it actually is true or could be true. How does that feel? In what ways might it actually feel true? What would be the consequences if it were true? Explore it; give it room to grow.
This is not a test of your original assumption, but a way to ferret out different assumptions and give them room to play in your judgment. Your original assumption may be correct, or it may be correct for now, or it may be as correct as some of its opposites. Maybe Tom really is a lousy communicator, but you're also not so good at hearing what Tom is on about, and in Tom's job it's not so important that he be a good communicator. In making your assumptions explicit and overturning them, you can find other truths — and in a deeply shifting strategic environment, we will need to find lots of new truths.
Overturn Assumptions
In this year of thinking dangerously, here are some assumptions to entertain that may be counter to the way you are thinking now. Try them on for your organization and your environment. See if the act of taking them, experimentally, as true turns up other thoughts that might add to the power of your judgment in the changing environment.
Assume brevity. Assume that your current product lines, business models, revenue streams and business structures have a short half-life — that they are not permanent but will disappear. Many businesses (such as consumer electronics) have this assumption built into their DNA. In health care, we make the opposite assumption: If we have a cancer program, if we make our margin on the employer side, if the sleep center is a good revenue stream, we assume permanence until proven otherwise. Assume brevity — actively search for, create and incubate alternatives.
Assume common ground. Assume that your business adversaries and rivals can be allies. The health plans, your crosstown rivals, or the city government may be making life difficult for you now. But under different business assumptions, for particular product lines, revenue streams or business structures, your strongest rivals may be your natural affiliates.
Assume all form is classical. If you are thinking of some new business direction, something that seems radically new to you, assume that somebody somewhere is already doing things this new way, is doing it well, and has learned something about how to do it. Assume that, rather than start from scratch, you can beg, borrow, pirate, buy or copy their expertise and experience — and then improve on it.
Assume new capacities. Assume that your organization does not have the capacities that it will need in its evolving environment.
Assume new abilities. Assume that your organization has latent abilities to learn, change and create that you have never tapped; that it is possible to tap them; and that you could learn how from other organizations.
Assume heterodoxy. Assume that there is no one right way to do health care, even for you to do health care in your market with your organization, but that there are many partially right ways.
Assume exotic provenance. Assume that the answers are not all in health care. As the business environment changes, we will increasingly find that we can learn things from other industries, that other industries represent a "target-rich environment" for new business ideas, revenue streams and risk structures that we can use in our organizations.
Assume the fruitfulness of challenge. Assume that a leader's most important task is to pose the unanswerable questions, the true challenges, to subordinates. Any question that actually has an answer is a technical question, not a leadership question. Leadership deals with the unanswerable, with where we could be and where we might go. Being the smartest person in the room and having the right answer is the smallest part of the job — and can actually get in the way of finding the best answer and the greatest intelligence the organization can manifest.
Assume curiosity. Curiosity is much more valuable than answers. Questions are far more useful than fixed opinions. Foster curiosity in your subordinates, in your customers, in your allies and potential allies. An organization displays and feeds curiosity by starting pilot programs, fostering new product lines, seeking out new allies and relationships, then seeing what works and pruning the rest.
Assume ruthlessness. Don't fall in love with what you create. It's a new environment. You have to try new things — and you have to kill off what does not work.
Assume competition. Assume that in a changing business environment, if an opportunity shows up, someone will take it. It could be you or it could be a competitor. The opportunity could be something not yet invented in your market, or it could be something you already do that someone else finds a way to do better, faster or cheaper.
Assume the bottom of the pyramid. Assume that there are opportunities on the low end, that there are ways to find margin even serving the least well-insured and the least well-employed. The reason is simple: The changes in the health care business environment likely will increase, rather than decrease, your exposure to the low end of the market, and will decrease the ways that you can offset losses in serving it. You have to find margin, and you will not find it if you assume it is not there.
Assume ignorance. Assume that you do not know enough about your own organization and its environment to make the best decisions: how much particular processes cost you, which of those costs are flexible, which are even unnecessary, where your revenue streams actually come from, who the true decision-makers are, both in incurring costs and in becoming customers. "Big data," the ability to drill down into the masses of information your organization produces and come up with answers to such questions, could be your friend.
Assume decision-making from ignorance. Assume that you will never really know enough, and you will have to make big decisions anyway.
Assume that it's always a decision. Assume that to make no decision, or to delay a decision, is itself a decision.
These are a few examples of the ways we must continually overturn and test our thinking, expose our illusions and bring a fresh mind to our strategic judgments. No matter how smart or how experienced, the mind whose expertise was formed in business models of the past decades is ill-equipped to make judgments in the Next Health Care as it forms and re-forms over the coming several years. When the mind of the leader learns to change first, then the organization can learn and change.
Joe Flower is a health care futurist and CEO of The Change Project Inc., and its health care education arm, Imagine What If. He is also a regular contributor to H&HN Daily and a member of Speakers Express. His new book,Healthcare Beyond Reform: Doing It Right for Half the Cost, will be published in March 2012 by Taylor and Francis.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
REH
Better Ways of Thinking about the Future
By Joe Flower January 24, 2012
How do you learn to "Think Different," as Steve Jobs' famous ads put it?
Let's think about the structure of thought for a moment. The great experimental psychologist Daniel Kahneman, in his recent book Thinking, Fast and Slow, shows how much of our thinking and decision-making is driven by illusions and assumptions, such as the "illusion of validity" (the false belief in the reliability of our own judgment), the "availability bias" (a biased judgment based on memories that are more easily available or more vivid) and the "endowment effect" (the tendency to value something more highly when we own it than when someone else owns it).
This makes sense. Kahneman's analysis resonates strongly with my experience working with executive health care teams, including providers, health plans and suppliers, and with governments in North America, Europe and China over several decades. Smart, seasoned executives can make seriously poor judgments, especially when the environment changes.
Curiously, these illusions, biases and assumptions are driven by our experiences. So, being more experienced does not necessarily exempt us from illusion, unless something in our process constantly and directly tests the results of our judgments (as, say, a robust retail market does on price setting). Even if the judgments are correct, they are based on an environment: in the jungle or the savanna, in a controlled market or a retail market, in a risk-bearing business arrangement or an endowed business arrangement. When our environment shifts, the illusions and biases and assumptions persist, even though they may be dangerously out of date.
We are in a rapidly shifting environment. Over the next several years, all health care leaders will be called on to make numerous strategic decisions and tactical choices that fundamentally will be different from decisions they are used to making. But they will be making those decisions with a mental apparatus formed in the old environment.
A Thought Exercise
How do we rethink our assumptions? How do we approach the unfolding situation with a continually fresh mind?
Here is a basic and enormously useful thought exercise. Take some time to write down a number of basic facts and beliefs about your organization, anything from facts such as "We own XYZ Home Care" to opinions such as "Tom's a lousy communicator." Then take one of these "truths" and find several ways to form an opposite of it.
An opposite of "We own XYZ Home Care" could be "We don't own XYZ Home Care," "Our crosstown rivals own XYZ Home Care," "XYZ Home Care owns us," or "We keep XYZ Home Care's assets, but farm out the management," or even "The business we now think of as 'home care' disappears and becomes something else," for instance.
The opposite of the opinion "Tom's a lousy communicator" could be "Tom's a great communicator," "I'm a lousy listener to Tom," or "There's really no need for Tom to be a great communicator."
Entertain one or another of these opposite assumptions for a while. Treat it as if it were true. Assume that, in some way, it actually is true or could be true. How does that feel? In what ways might it actually feel true? What would be the consequences if it were true? Explore it; give it room to grow.
This is not a test of your original assumption, but a way to ferret out different assumptions and give them room to play in your judgment. Your original assumption may be correct, or it may be correct for now, or it may be as correct as some of its opposites. Maybe Tom really is a lousy communicator, but you're also not so good at hearing what Tom is on about, and in Tom's job it's not so important that he be a good communicator. In making your assumptions explicit and overturning them, you can find other truths — and in a deeply shifting strategic environment, we will need to find lots of new truths.
Overturn Assumptions
In this year of thinking dangerously, here are some assumptions to entertain that may be counter to the way you are thinking now. Try them on for your organization and your environment. See if the act of taking them, experimentally, as true turns up other thoughts that might add to the power of your judgment in the changing environment.
Assume brevity. Assume that your current product lines, business models, revenue streams and business structures have a short half-life — that they are not permanent but will disappear. Many businesses (such as consumer electronics) have this assumption built into their DNA. In health care, we make the opposite assumption: If we have a cancer program, if we make our margin on the employer side, if the sleep center is a good revenue stream, we assume permanence until proven otherwise. Assume brevity — actively search for, create and incubate alternatives.
Assume common ground. Assume that your business adversaries and rivals can be allies. The health plans, your crosstown rivals, or the city government may be making life difficult for you now. But under different business assumptions, for particular product lines, revenue streams or business structures, your strongest rivals may be your natural affiliates.
Assume all form is classical. If you are thinking of some new business direction, something that seems radically new to you, assume that somebody somewhere is already doing things this new way, is doing it well, and has learned something about how to do it. Assume that, rather than start from scratch, you can beg, borrow, pirate, buy or copy their expertise and experience — and then improve on it.
Assume new capacities. Assume that your organization does not have the capacities that it will need in its evolving environment.
Assume new abilities. Assume that your organization has latent abilities to learn, change and create that you have never tapped; that it is possible to tap them; and that you could learn how from other organizations.
Assume heterodoxy. Assume that there is no one right way to do health care, even for you to do health care in your market with your organization, but that there are many partially right ways.
Assume exotic provenance. Assume that the answers are not all in health care. As the business environment changes, we will increasingly find that we can learn things from other industries, that other industries represent a "target-rich environment" for new business ideas, revenue streams and risk structures that we can use in our organizations.
Assume the fruitfulness of challenge. Assume that a leader's most important task is to pose the unanswerable questions, the true challenges, to subordinates. Any question that actually has an answer is a technical question, not a leadership question. Leadership deals with the unanswerable, with where we could be and where we might go. Being the smartest person in the room and having the right answer is the smallest part of the job — and can actually get in the way of finding the best answer and the greatest intelligence the organization can manifest.
Assume curiosity. Curiosity is much more valuable than answers. Questions are far more useful than fixed opinions. Foster curiosity in your subordinates, in your customers, in your allies and potential allies. An organization displays and feeds curiosity by starting pilot programs, fostering new product lines, seeking out new allies and relationships, then seeing what works and pruning the rest.
Assume ruthlessness. Don't fall in love with what you create. It's a new environment. You have to try new things — and you have to kill off what does not work.
Assume competition. Assume that in a changing business environment, if an opportunity shows up, someone will take it. It could be you or it could be a competitor. The opportunity could be something not yet invented in your market, or it could be something you already do that someone else finds a way to do better, faster or cheaper.
Assume the bottom of the pyramid. Assume that there are opportunities on the low end, that there are ways to find margin even serving the least well-insured and the least well-employed. The reason is simple: The changes in the health care business environment likely will increase, rather than decrease, your exposure to the low end of the market, and will decrease the ways that you can offset losses in serving it. You have to find margin, and you will not find it if you assume it is not there.
Assume ignorance. Assume that you do not know enough about your own organization and its environment to make the best decisions: how much particular processes cost you, which of those costs are flexible, which are even unnecessary, where your revenue streams actually come from, who the true decision-makers are, both in incurring costs and in becoming customers. "Big data," the ability to drill down into the masses of information your organization produces and come up with answers to such questions, could be your friend.
Assume decision-making from ignorance. Assume that you will never really know enough, and you will have to make big decisions anyway.
Assume that it's always a decision. Assume that to make no decision, or to delay a decision, is itself a decision.
These are a few examples of the ways we must continually overturn and test our thinking, expose our illusions and bring a fresh mind to our strategic judgments. No matter how smart or how experienced, the mind whose expertise was formed in business models of the past decades is ill-equipped to make judgments in the Next Health Care as it forms and re-forms over the coming several years. When the mind of the leader learns to change first, then the organization can learn and change.
Joe Flower is a health care futurist and CEO of The Change Project Inc., and its health care education arm, Imagine What If. He is also a regular contributor to H&HN Daily and a member of Speakers Express. His new book,Healthcare Beyond Reform: Doing It Right for Half the Cost, will be published in March 2012 by Taylor and Francis.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
Friday, November 4, 2011
"Learning Health Systems"
News release 11/4/11
IOM reports on efforts to develop a ‘learning health system’
The Institute of Medicine recently issued a report on efforts by its Roundtable on Value & Science-Driven Health Care to promote a “learning health system.” Guided by leaders from key stakeholder sectors, the Roundtable has worked since 2006 to accelerate the production and use of needed evidence on what works best in health care; characterize and explore the nature, potential and elements of a “learning health system” that yields continuous improvement in outcomes while reducing the costs of health and health care; and marshal collaborative action. The report summarizes a series of Roundtable publications that present a vision and strategies for a learning health system, and efforts by its Innovation Collaboratives to accelerate progress in five areas: best clinician practices, innovative effectiveness research, digital learning, evidence communication, and value incentives. Roundtable members include AHA Trustee Jonathan Perlin, M.D., president of clinical and physician services for HCA Inc., as well as other hospital leaders. For more on the initiative, visit www.iom.edu/vsrt.
IOM reports on efforts to develop a ‘learning health system’
The Institute of Medicine recently issued a report on efforts by its Roundtable on Value & Science-Driven Health Care to promote a “learning health system.” Guided by leaders from key stakeholder sectors, the Roundtable has worked since 2006 to accelerate the production and use of needed evidence on what works best in health care; characterize and explore the nature, potential and elements of a “learning health system” that yields continuous improvement in outcomes while reducing the costs of health and health care; and marshal collaborative action. The report summarizes a series of Roundtable publications that present a vision and strategies for a learning health system, and efforts by its Innovation Collaboratives to accelerate progress in five areas: best clinician practices, innovative effectiveness research, digital learning, evidence communication, and value incentives. Roundtable members include AHA Trustee Jonathan Perlin, M.D., president of clinical and physician services for HCA Inc., as well as other hospital leaders. For more on the initiative, visit www.iom.edu/vsrt.
Thursday, September 22, 2011
Are You Talking To Me?
Complete recognition is extended to Matthew Weinstock for his article, published September 22, 2011 in HH&N. Matthew Weinstock is the Senior Editor of Hospitals & Health Networks magazine.
Are You Talking to Me?
By Matthew Weinstock September 22, 2011
Better patient-physician communication is central to improving quality of care.
Since 2004, Bill Lee has had 10 heart attacks. That's not a typo: 10 heart attacks in 7 years.
He has coronary artery disease. Oh, and he's diabetic.
A few years ago, he was lying in a hospital bed after his seventh heart attack and his doctors told him, "There's nothing else we can do for you. You are just going to keep having heart attacks."
"That's not acceptable to me," he said. "I'm not going to accept your diagnosis and your prognosis."
From that moment, Lee took it upon himself to become an informed patient. He researched his conditions. He made a list of questions before every doctor's appointment and, importantly, he asked them. That was a new behavior for Lee. He used to be like so many of us, just accepting what the doctor said and taking his medicine, no questions asked.
Lee's compelling story is featured on a new website, "Questions are the Answer." Developed in partnership between the Agency for Healthcare Research and Quality and the Ad Council, the site is aimed at providers and patients, encouraging them to become more engaged in two-way communication.
"We know that when patients and clinicians communicate well, care is better. But in today's fast-paced health care system, good communication isn't always the norm," AHRQ Director Carolyn Clancy said in a statement. "This campaign reminds us all that effective communication between patients and their health care team is important and that it is possible — even when time is limited."
The AHRQ site, unveiled on Tuesday, contains a host of tools including one that lets patients create and prioritize a list of questions. Hospitals wanting to do a better job of promoting two-way communication can co-brand materials from the site.
Matthew and Carolyn Bucksbaum, meanwhile, are putting up $42 million to ensure that their home hospital, the University of Chicago Medical Center, bolsters doctor-patient communication. Matthew Bucksbaum is CEO of shopping mall behemoth General Growth Properties. The Bucksbaum Institute will "train medical students and faculty who, in turn, can serve as role models in communication and shared decision-making."
Of course, it is one thing to put up millions in the hopes that folks adopt shared decision-making, it's entirely another for that to become a reality. The National Institute for Health Care Reform on Tuesday issued a very insightful report detailing the many barriers to shared decision-making. The report, authored by researchers at the Center for Studying Health System Change and Mathematica Policy Research, also offers an array of policy solutions.
Shared decision making is slightly different from two-way communication. The latter can — should, I would argue — be used in any situation. Shared decision-making is typically used for "common health problems" for which there is more than one "medically acceptable treatment option," according to the NIHCR report. The idea is that an informed patient will work with his or her doctor to choose the best care for their particular case.
The authors note, however, that there are many roadblocks: an arcane payment system, clinicians poorly trained in the art of shared decision-making, malpractice concerns, low health literacy among patients, and, not insignificantly, "political hyperbole" that "can stifle discussion and support for shared decision-making." Think back to the arguments on end-of-life care during the health reform debate.
The report, however, points out that both the health reform and stimulus laws elevate shared decision-making through the promotion of patient-centered medical homes, the creation of the Patient-Centered Outcomes Research Institute and more.
But the authors suggest that we need not wait around for elements of those laws to take hold. No, there are some real solutions that could advance shared decision-making right now:
Reward providers. While providers wait for a shift from fee for service, CPT codes could be revised to pay for shared decision-making activity.
Do a better job of promoting and teaching the concept in medical school and create some continuing medical education programs.
Address liability concerns. In Washington, for instance, there are legal protections for physicians who engage in shared decision-making.
Provide patients with more tools/aids.
Tap into the power of electronic health and personal health records.
The shift to accountable care, the medical home, whatever catch phrase you want to use, hinges on the patient (and family) becoming an active participant in the care process. I know this all too well right now. I have a family member undergoing intense treatment for Stage 3 esophageal cancer. He is not a very good patient advocate, but his daughters are and they accompany him to every doctor's appointment armed with questions. Thankfully, his physicians are welcoming of their input and are fully engaged in a dialogue about his treatment plan. Can you say the same about your doctors?
I welcome your thoughts. Email me at mweinstock@healthforum.com.
Matthew Weinstock is the Senior Editor of Hospitals & Health Networks magazine.
Are You Talking to Me?
By Matthew Weinstock September 22, 2011
Better patient-physician communication is central to improving quality of care.
Since 2004, Bill Lee has had 10 heart attacks. That's not a typo: 10 heart attacks in 7 years.
He has coronary artery disease. Oh, and he's diabetic.
A few years ago, he was lying in a hospital bed after his seventh heart attack and his doctors told him, "There's nothing else we can do for you. You are just going to keep having heart attacks."
"That's not acceptable to me," he said. "I'm not going to accept your diagnosis and your prognosis."
From that moment, Lee took it upon himself to become an informed patient. He researched his conditions. He made a list of questions before every doctor's appointment and, importantly, he asked them. That was a new behavior for Lee. He used to be like so many of us, just accepting what the doctor said and taking his medicine, no questions asked.
Lee's compelling story is featured on a new website, "Questions are the Answer." Developed in partnership between the Agency for Healthcare Research and Quality and the Ad Council, the site is aimed at providers and patients, encouraging them to become more engaged in two-way communication.
"We know that when patients and clinicians communicate well, care is better. But in today's fast-paced health care system, good communication isn't always the norm," AHRQ Director Carolyn Clancy said in a statement. "This campaign reminds us all that effective communication between patients and their health care team is important and that it is possible — even when time is limited."
The AHRQ site, unveiled on Tuesday, contains a host of tools including one that lets patients create and prioritize a list of questions. Hospitals wanting to do a better job of promoting two-way communication can co-brand materials from the site.
Matthew and Carolyn Bucksbaum, meanwhile, are putting up $42 million to ensure that their home hospital, the University of Chicago Medical Center, bolsters doctor-patient communication. Matthew Bucksbaum is CEO of shopping mall behemoth General Growth Properties. The Bucksbaum Institute will "train medical students and faculty who, in turn, can serve as role models in communication and shared decision-making."
Of course, it is one thing to put up millions in the hopes that folks adopt shared decision-making, it's entirely another for that to become a reality. The National Institute for Health Care Reform on Tuesday issued a very insightful report detailing the many barriers to shared decision-making. The report, authored by researchers at the Center for Studying Health System Change and Mathematica Policy Research, also offers an array of policy solutions.
Shared decision making is slightly different from two-way communication. The latter can — should, I would argue — be used in any situation. Shared decision-making is typically used for "common health problems" for which there is more than one "medically acceptable treatment option," according to the NIHCR report. The idea is that an informed patient will work with his or her doctor to choose the best care for their particular case.
The authors note, however, that there are many roadblocks: an arcane payment system, clinicians poorly trained in the art of shared decision-making, malpractice concerns, low health literacy among patients, and, not insignificantly, "political hyperbole" that "can stifle discussion and support for shared decision-making." Think back to the arguments on end-of-life care during the health reform debate.
The report, however, points out that both the health reform and stimulus laws elevate shared decision-making through the promotion of patient-centered medical homes, the creation of the Patient-Centered Outcomes Research Institute and more.
But the authors suggest that we need not wait around for elements of those laws to take hold. No, there are some real solutions that could advance shared decision-making right now:
Reward providers. While providers wait for a shift from fee for service, CPT codes could be revised to pay for shared decision-making activity.
Do a better job of promoting and teaching the concept in medical school and create some continuing medical education programs.
Address liability concerns. In Washington, for instance, there are legal protections for physicians who engage in shared decision-making.
Provide patients with more tools/aids.
Tap into the power of electronic health and personal health records.
The shift to accountable care, the medical home, whatever catch phrase you want to use, hinges on the patient (and family) becoming an active participant in the care process. I know this all too well right now. I have a family member undergoing intense treatment for Stage 3 esophageal cancer. He is not a very good patient advocate, but his daughters are and they accompany him to every doctor's appointment armed with questions. Thankfully, his physicians are welcoming of their input and are fully engaged in a dialogue about his treatment plan. Can you say the same about your doctors?
I welcome your thoughts. Email me at mweinstock@healthforum.com.
Matthew Weinstock is the Senior Editor of Hospitals & Health Networks magazine.
Friday, August 26, 2011
Designing space for the high-tech patient room
With complete credit for authorship to John J. Skreenock, HEM as published in the August, 2011 issue of "HEALTH FACILITIES MANGEMENT"
Designing space for the high-tech patient room
By John J. Skreenock, HEM
When planning for new patient rooms, today's health facility professionals have quite the challenge. They must ensure that the room design will provide effective, state-of-the-art technology when the space is initially occupied and adapt to future technologies.
This is easier said than done. Depending on the size of the project and funding, it may be years before the space is actually constructed and ready for occupancy. Working closely with a knowledgeable medical-equipment planner will increase the probability that the design will last well into the future.
Three types of rooms
Most hospitals have three general types of patient rooms, depending on the acuity level of the patient: intensive care unit (ICU) rooms, step-down or intermediate care rooms, and acute care rooms.
ICU rooms are grouped together in a unit to take advantage of the nursing skills required to care for these patients. These nursing units are called medical ICUs, surgical ICUs, cardiovascular ICUs and cardiac ICUs, to name a few.
Each type of patient room must accommodate an extensive array of specialized medical equipment required to care for the clinical needs of the specific patient population. Consideration also must be given to the safe and efficient use of fixed and movable medical equipment brought in to care for the patient. They also must accommodate nursing staff and the cardiac resuscitation team, if they are needed. Consequently, these rooms need to be designed to allow safe, easy access to all sides of the patient.
Once the types of equipment that could be used in the room and the location and position of the patient are known, the room layout can begin.
Room organization
A major consideration for an ICU room is getting the utilities to all the movable and portable equipment brought in and out of the room during a patient's stay. The ceiling, wall and floor space are usually at a premium in these rooms and the anticipated use of specific medical equipment will dictate the location of both the fixed and mobile medical equipment.
Types of utilities and outlets that typically need to be available in the room range from electrical and emergency power receptacles for equipment (e.g., ventilators, hemodialysis units and physiologic monitors); to low-voltage connections for various devices (e.g., television, information technology data lines for bedside physiologic monitors, electronic medical records and alarm monitoring); and medical gases (e.g., oxygen and medical air and vacuum outlets).
There are several methods of getting the utilities near the patient. Fixed floor-to-ceiling columns and movable ceiling- or wall-mounted booms have been gaining popularity over a standard prefabricated headwall or mounting the utilities directly on the walls adjacent to the patient bed. The columns provide better organization of the devices, better accessibility for staff and reduced wire and tube clutter, and fewer tripping hazards.
The columns and booms also allow for some bed movement to take advantage of window vistas, which have been attributed to patient well-being. However, window views may not always be an option due to existing external obstructions. One innovative hospital solved that dilemma by planning to install windowlike frames to display real-time camera views from several locations on the hospital roof.
If a fixed column or boom is used, space on the ceiling needs to be evaluated for proper layout, ceiling support structure and lighting requirements. Some ICU rooms may be equipped with one or two special procedural lights mounted in the ceiling above the patient for procedures that could be performed in the room in an emergency. Procedure lights sometimes are specified for ICU rooms. One model enables lights to be directed to the specific site using a wand- or wall-mounted panel.
Another consideration competing for ceiling space is the patient lift. Patient lifts can be mounted to the ceiling, installed as freestanding structures, or attached to a boom. The Facility Guidelines Institute's 2010 Guidelines for Design and Construction of Health Care Facilities identifies the need to conduct a patient handling and movement assessment and to address this during the construction process, which could have major implications for room design.
If there is a possibility of installing ceiling-mounted lifts in the future it is prudent to plan for them in the early design stages to prevent clashes with structures above the ceiling or to add structural support while the room is being planned.
Nursing staff need good visibility to the patient from the hallway. This is accomplished by using a significant amount of glass. However, sometimes privacy is needed for the patient and switchable or so-called "smart" glass is used in some units to accommodate the dual needs of privacy and observation.
With the touch of a switch, the glass changes from transparent to opaque, blocking light and providing privacy and security. This high-tech glass eliminates the need for blinds or curtains that may present an infection control risk and pose a cleaning challenge for environmental services. These glass panels are relatively expensive compared with that of standard glass, however.
Equipment needs
This is Modular Services Company's equipment solution for neonatal intensive care operations. The design team must ensure that the room is future-proofed for all of the equipment that may be fixed or wheeled into the room. It needs to consider the possible uses of the room when it is completed as well as how the room may be used in the future.
Ultimately, the type of critical care unit and patient determines which technologies are needed in the room. Most ICU rooms include ventilators; physiologic monitors mounted on a wall, boom or column; IV poles that are movable or mounted to a column or boom that can accommodate multiple IV pumps; and patient-controlled analgesia pumps. All of these may require multiple emergency-power receptacles.
Many of these devices will be integrated with the hospital electronic records through wireless connections. This integration requires that the information technology (IT) group be intimately involved with the planning of the room design and antenna placement.
Some facilities monitor ICU patients from a remote site, often called the electronic ICU or command center. For remote-monitored rooms, a pan-tilt-zoom (PTZ) camera, microphone and speakers — either ceiling- or wall-mounted — are needed to enable the remote site to communicate with the patient or nursing staff and observe patient and vital equipment displays and settings.
There is also a telepresence robot on the market that can be maneuvered into the room to gather the same type of information. This type of device requires a clear floor path through the room without wires, tubes or cables on the floor.
Intelligent patient beds are another new component in high-tech patient rooms. They not only require electrical power, but also a low-voltage data jack to connect to the hospital infrastructure for nurse-call and bed-exit alarms to monitor for fall risks. They also require connections for electronic medical records.
The flow of patient care within the room needs to be planned carefully to accommodate wireless workstations on wheels (WOWs), which typically are used for patient charting and confirmation of medication delivery. While they do not require an electrical receptacle or data jack, they take up space and need to be considered in the room layout. The typical footprint for the WOW is approximately 26 inches wide by 28 inches deep; however, newer tablet devices eventually may supersede WOWs for charting patient care.
As more and more new technology is introduced for patient care, the design team faces new challenges in providing the required utilities and adequate footprint. For example, ICU patients too ill to be moved for imaging studies need space in their rooms to accommodate mobile imaging devices like a mobile C-arm radiography or fluoroscopy unit.
The type of patient receiving care will dictate the equipment and utility requirements for the room. Here are some examples of typical ICU room equipment that have relatively large footprints and their utility requirements:
Hemodialysis equipment using continuous renal replacement therapy requires a hot and cold mixed water supply, drain and emergency power.
Ventilators require emergency electrical power, a medical air connection and a data connection for alarm management.
Hypo/hyperthermia units require electrical power.
Intra-aortic balloon pumps used in the cardiovascular ICU require emergency electrical power.
Video endoscopy carts or bronchoscopy carts require electrical power.
C-arms require electrical power.
Space also is required to ensure quick patient access by the resuscitation team with their resuscitation cart or crash cart.
Other types of ICU rooms may require very different equipment needs. For example, specialized orthopedic beds in a trauma ICU that provides for traction are usually larger and have bars that extend toward the ceiling. These require clear space above the bed to accommodate the bars. Likewise, neurologic intensive care areas may call for specialized monitoring equipment that require data jacks as well as a ceiling- or wall-mounted PTZ camera and microphone and speakers.
Point-of-care technology may have an impact on additional requirements for the design of the room as blood gas monitoring and portable ultrasound are becoming more prevalent. The key is using the medical-equipment planner to provide those glimpses into the technologies of the future of patient care and to raise the awareness of potential implications of the design on future needs.
Decisions must be made about making the investment to provide for the necessary flexibility, or at least addressing the potential impact, and designing the room to be able to add future equipment or technologies.
Beyond the ICU
Critical care areas aren't the only sections of hospitals with high-tech patient rooms. Step-down rooms and acute care rooms have their share of technologies requiring planning and installation considerations.
Step-down rooms are associated with the ICUs and have a reduced complement of equipment needs depending on the type of step-down unit. These rooms may be monitored via a telemetry transmitter that sends a patient's heart trace signals and maybe pulse oximetry to a central monitor that is being watched by a trained monitor technician. A step-down room also has a lesser requirement for both the regular and emergency electrical power systems and the number of oxygen, medical air and vacuum outlets. The design may have to accommodate fixed-ceiling patient lifts.
The acute care room has an even smaller complement of medical equipment and, consequently, less infrastructure. Some health care facilities are designing step-down and acute care rooms to be more like hotel rooms, conveying a less clinical and more comforting experience for both patients and their visiting family and friends.
Many hospitals also treat critically ill infants and children. Neonatal and pediatric ICUs have highly specialized equipment and unique room design requirements.
More of these rooms are being designed as private rooms to provide better control over the sensory environment for the neonate. Alarm management from the equipment in the room requires data jacks. Lines of site that are lost due to privacy and communication challenges need to be addressed with technology because of hard walls. Equipment to care for the neonate can be mounted on the wall or suspended from the ceiling on a boom. Utilities like regular and emergency electrical power are needed in sufficient quantity. Additionally, medical air, oxygen and vacuum are required, as are data jacks for connection to the central monitoring and the hospital information systems.
Planning for future
While considering the equipment now used in each type of room, hospital designers and facility managers must work in conjunction with clinicians to consider the potential use of the room in the future.
It is generally easier and less expensive to include additional space, electrical and data outlets, and utilities while in the design and construction phase of a project, rather than waiting until the spaces are occupied with patients and then deciding an upgrade is needed.
John J. Skreenock, HEM, is senior associate for the Applied Solutions Group at ECRI Institute, Plymouth Meeting, Pa. He can be reached at jskreenock@ecri.org.
Sidebar - Flexible rooms provide savings
A medium-sized hospital planned to renovate a couple of its acute- care nursing floors and convert all of the semiprivate rooms to private rooms, creating a new intensive care unit (ICU) step-down space.
While initial plans called for the rooms to be used for step-down patients, the longer range plan was to convert these spaces to ICU rooms when needed. For a step-down room, telemetry monitoring is sufficient. However, for future use as an ICU setting, centrally monitored, wall-mounted physiologic monitors or other high-technology equipment would be required.
With that in mind, the design had to be modified. The hospital decided to plan the rooms with increased infrastructure to handle the future conversion. Increased gas and vacuum capacity for additional outlets and additional electrical power and data jacks allowed for future upgrades.
These design changes now allow the high-technology equipment that is routinely deployed in the ICU to be used in these rooms in the future. The cost for such infrastructure at such an early stage is a fraction of the cost required in the future to convert the rooms.
However, cost is only one factor that would be considered for future conversion. If the hospital had not increased the infrastructure during the original renovation, a future conversion would have faced major complications, including the potential loss of revenue while the rooms were being renovated extensively, disruption to patient care and department operations, complex infection-control issues and a longer time to complete the conversion.
With all of these considerations, the conversion for ICU patients may never have happened.
Sidebar - Prepping for mass patient surges
When hospitals need extra space for unplanned patients in mass numbers, such as during or after a flu epidemic or a disaster with mass casualties, some facilities provide a flexible solution for allowing the census in a particular nursing department to flex up in times of need and then flex back down when the need subsides.
A portion of the acute care private rooms are designed with the ability to accommodate two patients in the same room, essentially creating a semiprivate room. This flexibility is provided by having the room designed with built-in infrastructure, such as utilities to accommodate two beds.
The design requires two headwall arrangements, each with enough gas and vacuum outlets; regular and emergency power; data jacks for plugging in equipment that communicates with the hospital's information systems; and separate lighting controls for each bed. Movable equipment required for patient care, like beds and IV pumps on poles, can be wheeled in when needed.
The second bed can be set up similar to the first but may not need all the amenities, because it only would be used for a short duration. Flexibility designed into the rooms allows for an unexpected short uptick in the hospital census.
The surge plan then will call for fixed medical equipment as well as additional mobile medical equipment to provide patient care. The mobile equipment may be relocated from another area of the facility, from storage or requisitioned from local rental firms.
This article first appeared in the August 2011 issue of HFM magazine.
Designing space for the high-tech patient room
By John J. Skreenock, HEM
When planning for new patient rooms, today's health facility professionals have quite the challenge. They must ensure that the room design will provide effective, state-of-the-art technology when the space is initially occupied and adapt to future technologies.
This is easier said than done. Depending on the size of the project and funding, it may be years before the space is actually constructed and ready for occupancy. Working closely with a knowledgeable medical-equipment planner will increase the probability that the design will last well into the future.
Three types of rooms
Most hospitals have three general types of patient rooms, depending on the acuity level of the patient: intensive care unit (ICU) rooms, step-down or intermediate care rooms, and acute care rooms.
ICU rooms are grouped together in a unit to take advantage of the nursing skills required to care for these patients. These nursing units are called medical ICUs, surgical ICUs, cardiovascular ICUs and cardiac ICUs, to name a few.
Each type of patient room must accommodate an extensive array of specialized medical equipment required to care for the clinical needs of the specific patient population. Consideration also must be given to the safe and efficient use of fixed and movable medical equipment brought in to care for the patient. They also must accommodate nursing staff and the cardiac resuscitation team, if they are needed. Consequently, these rooms need to be designed to allow safe, easy access to all sides of the patient.
Once the types of equipment that could be used in the room and the location and position of the patient are known, the room layout can begin.
Room organization
A major consideration for an ICU room is getting the utilities to all the movable and portable equipment brought in and out of the room during a patient's stay. The ceiling, wall and floor space are usually at a premium in these rooms and the anticipated use of specific medical equipment will dictate the location of both the fixed and mobile medical equipment.
Types of utilities and outlets that typically need to be available in the room range from electrical and emergency power receptacles for equipment (e.g., ventilators, hemodialysis units and physiologic monitors); to low-voltage connections for various devices (e.g., television, information technology data lines for bedside physiologic monitors, electronic medical records and alarm monitoring); and medical gases (e.g., oxygen and medical air and vacuum outlets).
There are several methods of getting the utilities near the patient. Fixed floor-to-ceiling columns and movable ceiling- or wall-mounted booms have been gaining popularity over a standard prefabricated headwall or mounting the utilities directly on the walls adjacent to the patient bed. The columns provide better organization of the devices, better accessibility for staff and reduced wire and tube clutter, and fewer tripping hazards.
The columns and booms also allow for some bed movement to take advantage of window vistas, which have been attributed to patient well-being. However, window views may not always be an option due to existing external obstructions. One innovative hospital solved that dilemma by planning to install windowlike frames to display real-time camera views from several locations on the hospital roof.
If a fixed column or boom is used, space on the ceiling needs to be evaluated for proper layout, ceiling support structure and lighting requirements. Some ICU rooms may be equipped with one or two special procedural lights mounted in the ceiling above the patient for procedures that could be performed in the room in an emergency. Procedure lights sometimes are specified for ICU rooms. One model enables lights to be directed to the specific site using a wand- or wall-mounted panel.
Another consideration competing for ceiling space is the patient lift. Patient lifts can be mounted to the ceiling, installed as freestanding structures, or attached to a boom. The Facility Guidelines Institute's 2010 Guidelines for Design and Construction of Health Care Facilities identifies the need to conduct a patient handling and movement assessment and to address this during the construction process, which could have major implications for room design.
If there is a possibility of installing ceiling-mounted lifts in the future it is prudent to plan for them in the early design stages to prevent clashes with structures above the ceiling or to add structural support while the room is being planned.
Nursing staff need good visibility to the patient from the hallway. This is accomplished by using a significant amount of glass. However, sometimes privacy is needed for the patient and switchable or so-called "smart" glass is used in some units to accommodate the dual needs of privacy and observation.
With the touch of a switch, the glass changes from transparent to opaque, blocking light and providing privacy and security. This high-tech glass eliminates the need for blinds or curtains that may present an infection control risk and pose a cleaning challenge for environmental services. These glass panels are relatively expensive compared with that of standard glass, however.
Equipment needs
This is Modular Services Company's equipment solution for neonatal intensive care operations. The design team must ensure that the room is future-proofed for all of the equipment that may be fixed or wheeled into the room. It needs to consider the possible uses of the room when it is completed as well as how the room may be used in the future.
Ultimately, the type of critical care unit and patient determines which technologies are needed in the room. Most ICU rooms include ventilators; physiologic monitors mounted on a wall, boom or column; IV poles that are movable or mounted to a column or boom that can accommodate multiple IV pumps; and patient-controlled analgesia pumps. All of these may require multiple emergency-power receptacles.
Many of these devices will be integrated with the hospital electronic records through wireless connections. This integration requires that the information technology (IT) group be intimately involved with the planning of the room design and antenna placement.
Some facilities monitor ICU patients from a remote site, often called the electronic ICU or command center. For remote-monitored rooms, a pan-tilt-zoom (PTZ) camera, microphone and speakers — either ceiling- or wall-mounted — are needed to enable the remote site to communicate with the patient or nursing staff and observe patient and vital equipment displays and settings.
There is also a telepresence robot on the market that can be maneuvered into the room to gather the same type of information. This type of device requires a clear floor path through the room without wires, tubes or cables on the floor.
Intelligent patient beds are another new component in high-tech patient rooms. They not only require electrical power, but also a low-voltage data jack to connect to the hospital infrastructure for nurse-call and bed-exit alarms to monitor for fall risks. They also require connections for electronic medical records.
The flow of patient care within the room needs to be planned carefully to accommodate wireless workstations on wheels (WOWs), which typically are used for patient charting and confirmation of medication delivery. While they do not require an electrical receptacle or data jack, they take up space and need to be considered in the room layout. The typical footprint for the WOW is approximately 26 inches wide by 28 inches deep; however, newer tablet devices eventually may supersede WOWs for charting patient care.
As more and more new technology is introduced for patient care, the design team faces new challenges in providing the required utilities and adequate footprint. For example, ICU patients too ill to be moved for imaging studies need space in their rooms to accommodate mobile imaging devices like a mobile C-arm radiography or fluoroscopy unit.
The type of patient receiving care will dictate the equipment and utility requirements for the room. Here are some examples of typical ICU room equipment that have relatively large footprints and their utility requirements:
Hemodialysis equipment using continuous renal replacement therapy requires a hot and cold mixed water supply, drain and emergency power.
Ventilators require emergency electrical power, a medical air connection and a data connection for alarm management.
Hypo/hyperthermia units require electrical power.
Intra-aortic balloon pumps used in the cardiovascular ICU require emergency electrical power.
Video endoscopy carts or bronchoscopy carts require electrical power.
C-arms require electrical power.
Space also is required to ensure quick patient access by the resuscitation team with their resuscitation cart or crash cart.
Other types of ICU rooms may require very different equipment needs. For example, specialized orthopedic beds in a trauma ICU that provides for traction are usually larger and have bars that extend toward the ceiling. These require clear space above the bed to accommodate the bars. Likewise, neurologic intensive care areas may call for specialized monitoring equipment that require data jacks as well as a ceiling- or wall-mounted PTZ camera and microphone and speakers.
Point-of-care technology may have an impact on additional requirements for the design of the room as blood gas monitoring and portable ultrasound are becoming more prevalent. The key is using the medical-equipment planner to provide those glimpses into the technologies of the future of patient care and to raise the awareness of potential implications of the design on future needs.
Decisions must be made about making the investment to provide for the necessary flexibility, or at least addressing the potential impact, and designing the room to be able to add future equipment or technologies.
Beyond the ICU
Critical care areas aren't the only sections of hospitals with high-tech patient rooms. Step-down rooms and acute care rooms have their share of technologies requiring planning and installation considerations.
Step-down rooms are associated with the ICUs and have a reduced complement of equipment needs depending on the type of step-down unit. These rooms may be monitored via a telemetry transmitter that sends a patient's heart trace signals and maybe pulse oximetry to a central monitor that is being watched by a trained monitor technician. A step-down room also has a lesser requirement for both the regular and emergency electrical power systems and the number of oxygen, medical air and vacuum outlets. The design may have to accommodate fixed-ceiling patient lifts.
The acute care room has an even smaller complement of medical equipment and, consequently, less infrastructure. Some health care facilities are designing step-down and acute care rooms to be more like hotel rooms, conveying a less clinical and more comforting experience for both patients and their visiting family and friends.
Many hospitals also treat critically ill infants and children. Neonatal and pediatric ICUs have highly specialized equipment and unique room design requirements.
More of these rooms are being designed as private rooms to provide better control over the sensory environment for the neonate. Alarm management from the equipment in the room requires data jacks. Lines of site that are lost due to privacy and communication challenges need to be addressed with technology because of hard walls. Equipment to care for the neonate can be mounted on the wall or suspended from the ceiling on a boom. Utilities like regular and emergency electrical power are needed in sufficient quantity. Additionally, medical air, oxygen and vacuum are required, as are data jacks for connection to the central monitoring and the hospital information systems.
Planning for future
While considering the equipment now used in each type of room, hospital designers and facility managers must work in conjunction with clinicians to consider the potential use of the room in the future.
It is generally easier and less expensive to include additional space, electrical and data outlets, and utilities while in the design and construction phase of a project, rather than waiting until the spaces are occupied with patients and then deciding an upgrade is needed.
John J. Skreenock, HEM, is senior associate for the Applied Solutions Group at ECRI Institute, Plymouth Meeting, Pa. He can be reached at jskreenock@ecri.org.
Sidebar - Flexible rooms provide savings
A medium-sized hospital planned to renovate a couple of its acute- care nursing floors and convert all of the semiprivate rooms to private rooms, creating a new intensive care unit (ICU) step-down space.
While initial plans called for the rooms to be used for step-down patients, the longer range plan was to convert these spaces to ICU rooms when needed. For a step-down room, telemetry monitoring is sufficient. However, for future use as an ICU setting, centrally monitored, wall-mounted physiologic monitors or other high-technology equipment would be required.
With that in mind, the design had to be modified. The hospital decided to plan the rooms with increased infrastructure to handle the future conversion. Increased gas and vacuum capacity for additional outlets and additional electrical power and data jacks allowed for future upgrades.
These design changes now allow the high-technology equipment that is routinely deployed in the ICU to be used in these rooms in the future. The cost for such infrastructure at such an early stage is a fraction of the cost required in the future to convert the rooms.
However, cost is only one factor that would be considered for future conversion. If the hospital had not increased the infrastructure during the original renovation, a future conversion would have faced major complications, including the potential loss of revenue while the rooms were being renovated extensively, disruption to patient care and department operations, complex infection-control issues and a longer time to complete the conversion.
With all of these considerations, the conversion for ICU patients may never have happened.
Sidebar - Prepping for mass patient surges
When hospitals need extra space for unplanned patients in mass numbers, such as during or after a flu epidemic or a disaster with mass casualties, some facilities provide a flexible solution for allowing the census in a particular nursing department to flex up in times of need and then flex back down when the need subsides.
A portion of the acute care private rooms are designed with the ability to accommodate two patients in the same room, essentially creating a semiprivate room. This flexibility is provided by having the room designed with built-in infrastructure, such as utilities to accommodate two beds.
The design requires two headwall arrangements, each with enough gas and vacuum outlets; regular and emergency power; data jacks for plugging in equipment that communicates with the hospital's information systems; and separate lighting controls for each bed. Movable equipment required for patient care, like beds and IV pumps on poles, can be wheeled in when needed.
The second bed can be set up similar to the first but may not need all the amenities, because it only would be used for a short duration. Flexibility designed into the rooms allows for an unexpected short uptick in the hospital census.
The surge plan then will call for fixed medical equipment as well as additional mobile medical equipment to provide patient care. The mobile equipment may be relocated from another area of the facility, from storage or requisitioned from local rental firms.
This article first appeared in the August 2011 issue of HFM magazine.
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