May 2, 2009 | by Peter Downs, Editor
Robert Porter, executive vice president, strategy and business development, SSM Health Care, can spend 45 minutes talking about what is new or different about patient rooms at SSM’s new 154-bed St. Clare Hospital in Fenton, MO, and even then he won’t have exhausted the subject. To Porter, the patient room at St. Clare Hospital is the architectural center of how SSM has re-envisioned hospital care. That re-envisioning led SSM to design the new hospital in a new way, build it in a new way, and ultimately operate it in a new way.
With hospital costs nationally outpacing the ability of people to pay and hospitals errors making sick, SSM decided “it was time to fundamentally rethink what we do,” Porter said. The first “visioning” session for the new $230 million hospital was in April 2005. The goals were easily stated – improve the patient experience and reduce costs – but the processes of accomplishing them were very complex.
Changing the design process
Porter said SSM’s approach to St. Clare Hospital differed in four fundamental ways from the typical hospital design process:
“That gave us high level planning and then we went down into the details, functions, and spaces,” he said.
“In the traditional design process, you go to the departments and ask them what volume of work they will have and what problems do they need fixed. But then you’re just putting new building blocks on the same chassis. That is about how health care is produced, not how it is experienced,” he said.
Hummel, Green and Abrahamson, Inc.of Milwaukee, WI was the primary architect on the hospital, with Mackey Mitchell Associates serving as the local architect. Mackey Mitchell Associates was the primary architect on the connected medical office building and ambulatory surgery center.
As it turned out, there was a lot of overlap between sources of patient dissatisfaction and inefficiency and waste. Patients hated being left in a hall somewhere to wait for the next thing to happen to them. And one of the things SSM learned from lean manufacturing was that anything that interrupts the flow of work increases waste and inefficiency.
“One of the biggest sources of frustration and waste is waiting time,” Porter said. To improve flow, SSM decided to invest more capital up front to duplicate important technologies in different departments instead of funneling everyone through one place. So, the emergency department and the ambulatory center got their own radiology equipment, for example. “Hospitals traditionally tried to save capital by investing in one radiology department. But having to take patients from all over the hospital to radiology and have them wait in the hallways until there is an opening backs up everyone else and causes tremendous waste. So we gave the departments that most use radiology their own equipment,” he said.
The theme of improving the patient experience runs from the campus sight plan and signs and cues to help visitors find their way to the artwork in patient rooms and public areas
“From our ring road, you have four choices: the emergency entrance, the public entrance, the medical office building, and the procedure center. In addition to signs, each has its own distinctive architectural markings. We’ve distributed parking to correspond with services, and each entrance has its own reception area,” Porter said.
Spellman Brady selected the artwork. By coincidence, Diana Spellman was undergoing treatments for cancer while she was working on the St. Clare hospital project. “I was coming from radiation treatments to go into high level meetings and I felt like I was glowing. I had to tell them,” she said. “I was able to bring experience and view as patient to selecting artwork. To really be patient centered it has to create positive, uplifting experience for patients… Some dated hospital rooms really make you sicker than you are sick because they are so depressing,” she said.
“They let us push the envelope in choosing artwork that is uplifting and colorful, and in letting us use different media. We used glass, sculpture, custom photography, and more. It was very impressive that the administration put that kind of thought into it,” she said.
“This hospital is designed to be more restful. We looked at noise, light, and décor all with an eye to accelerating patient recovery. By putting patients in a more healing environment we save dollars that would otherwise be spent on longer stays,” Porter said.
“We even have an open MRI to reduce stress on those patients who are claustrophobic or just don’t like closed spaces,” he said.
SSM also put a lot of thought into alleviating another major source of patient dissatisfaction and waste: errors.
The Institute of Medicine called medical errors “a leading cause of death and injury” in a report to Congress in 2006. The Institute of Medicine (IOM) estimated that nationwide, roughly two out of every 100 people admitted to a hospital would suffer an injury as a result of a medical error while in the hospital. The IOM estimated that between 44,000 and 98,000 people a year were killed by preventable errors in hospitals, more than died every year in car accidents and more than were killed by breast cancer or aids. Indeed, the IOM called hospital errors the eighth-leading cause of death in the United States. The IOM also estimated that the direct medical charges associated with treating hospital errors totaled between $9 billion and $15 billion.
SSM and its designers made several design decisions in order to reduce medical errors and make sure the hospital provides “the right care in the right place at the right time,” said Porter. The most basic decision was standardization.
“All eight of the operating rooms are oriented the same. Everything in them is the same and equipment hangs from ceiling booms,” Porter said. “The standardization is to cut down on mistakes resulting from things not being where you expect them to be,” he said. The operating rooms also are substantially larger than in the old hospital: 600 square feet compared to about 400; and the one cardiac operating room is 800 square feet in size. Plus, they are organized ergonomically and they all have advanced operating lights that do not cast any shadows.
All patient rooms also have the same configuration and handedness in order to minimize errors. They all are private rooms and bathroom is in the same corner in every room, instead of neighboring rooms having bathrooms back-to-back. That meant twice as many stacks for plumbing. “It cost $3 - 4,000 more per room to make each room the same instead of having bathrooms head to head,” Porter said, or about $500,000 more for the whole hospital. How many mistakes do they have to avoid in order to make up that cost? “I don’t know,” Porter said. “In a high intensity environment, standardization unquestionably makes for greater reliability, but it is hotly debated, even within our own organization, on whether it makes a difference in patient rooms.” Nevertheless, SSM spent the money, because, “we wanted to make the optimum safe environment for our patients,” he said.
The bathrooms in the patient rooms are not rectangular boxes. Porter called the five-sided bathrooms, “one of the more brilliant architectural decisions,” in the hospital’s design. Having a slanted wall nearer the patient bed, “preserves the patient’s view of the window and creates more space in the room,” he said, and research has shown that the ability to see out a window speeds a patient’s recovery.
Changing the construction process
Changing the design process was one piece of how SSM sought to reinvent the hospital; changing the construction process was another.
“The way the trades were engaged was different from traditional construction,” said Timothy Gunn, project director Alberici Constructors, the general contractor. “And their relationship with the design team was very different from the traditional [relationship],” he said.
SSM used a process called “lean construction” to build the new 430,000-square-foot hospital. Alberici, SSM, and the architect selected the main trade contractors early – Murphy Co. Mechanical Contractors, Guarantee Electrical Co., St. Louis Automatic Sprinkler Co., and Niehaus Construction Services. All of those contractors were on cost-plus-fee contracts. “That let them be nimble in implementing change, and in a hospital, where you want to include the most modern equipment, there is a lot of change,” said Gunn.
The trades contractors worked together in “the big room,” as Gunn called it, a doublewide trailer full of computers and flat screen display panels. There, detailers from all the trades worked together to create a part of a building information model, in this case a three dimensional model of everything above the ceiling with descriptions –– all of the ductwork, conduit, and piping –– so that they could coordinate all of the above the ceiling work and maximize how much they made in the shop and trucked to the site. This effort was accomplished utilizing 3D modeling within a web-based server system that allowed real-time design-engineering coordination between the project design team.
“The electrical, mechanical, and fire protection systems were all virtually built in the 3-D model before we started installing them,” said Mark Bengard, senior vice president of Murphy Co., which installed all the piping for medical gases, plumbing, and heating and cooling. “SSM has a 3-D model now so if they need to track down a valve they can look in their electronic model instead of disturbing patients by lifting ceiling tiles or opening access doors in the walls to find it. That is a powerful tool and it is something almost no one else has,” he says.
Modeling all of the above the ceiling work electronically produced two other important results. “We prefabbed in excess of what would be typical, due to the confidence everyone had that they would have the space to put their work,” Gunn said. And all the planning helped the trades make up lost time. “In 2008 we faced one of the wettest years in history. We had lost the planned number of weather days for the entire project by March, and being behind on the exterior put us behind on the interior finish,” Gunn said. Having built the job electronically in 3-D, the trades contractors could see that they could get creative with sequencing the above the ceiling work to make up lost time.
“We didn’t necessarily have to have mechanical contractor in first in all phases,” said Steve Kellenberger, director of construction for Guarantee Electrical. “As long as you followed the design and put your work where you were supposed to, you could go in and put your work out of the typical sequence. It eliminated conflicts between tradesmen,” he said.
With that kind of cooperation, said Gunn, “we were able to make up time and maintain the scheduled opening date.”
Just as electronic records – the 3-D model – played a crucial role in the construction of St. Clare Hospital, they also will be a crucial part of what makes St. Clare Hospital different. “Our data backbone is as big and complex as our electrical backbone. That is because the single most important variable in health care is information,” Porter said.
“The low voltage work here was extraordinarily complicated. They included electronic records, VOIP (voice over internet protocol), nurse call systems, telemetry, security, and paging,” Gunn said. Guarantee Electrical Co. was the single source electrical installation contractor installing the power, lighting, emergency, technology, data, fire alarm and security systems.
“We made points of data entry ubiquitous,” Porter said. “No more paper charts,” he said. To make sure that data is reliably and quickly entered, St. Clare Hospital has an electronic record portal in each patient room and also outside each room at a window at which a nurse can observe the patient and make notes.
The electronic record also is designed to cut down on medication mistakes via its connection to a medical dispensing system in each room. According to the Institute of Medicine, medication errors alone kill more people annually than do workplace accidents.
Porter explained how the medical dispensing system works: “The pharmacist stocks the patient’s drugs in the room in a secure drawer that can be opened only by entering the correct security code into the electronic record portal. Each prescription has a bar code for the drug and a bar code for the patient. This reduces the number of people handling the drug to three, which should reduce errors.” And since the physician orders the prescription electronically, there should occur no handwriting deciphering errors.
The same system data wiring backbone that supports electronic records and the medical dispensing system also lets the operations department at St. Clare Hospital remote control the temperature in every patient room, office, and surgery suite. “We use a Trane Tracer Summit Automated Control System to control the heat in each room individually from the control room or the Internet, and we can give the room occupants control within a set band of temperatures,” said Andy Gratton, team leader of plant operations.
With the Trane Summit System, “they have an ability they never had before to see hundreds of pressures and temperature in chiller. They can get data and keep track of issues as they’re developing and schedule maintenance before issues become a problem,” Bengard said. “A good building management system can make a great difference in the time spend on a problem,” Gratton added.
Some of the equipment controlled via the Trane Summit System is new to the St. Louis area, but all of it “is light years from where they were in their old building,” Bengard said.
The new steam boilers, for example, are much more efficient than the old ones. “We went from a traditional, 692 horsepower boiler system to two, 200 hp and two 300 horsepower boilers.” The new boilers can operate at two stages, 50 percent or 100 percent, and they can cycle on and off, whereas SSM had to keep the old boiler system idling. The new boilers “can go from zero to 80 pounds of steam in five minutes, while with the traditional boilers we would take two days to do that so that we didn’t crack the refractory wall. That makes the new ones more efficient, because we don’t have to keep operating them when they aren’t needed,” Gratton said.
“We did a lot of research when selecting boilers and actually took [Gratton and other SSM representatives] on a trip to the closest ones in operation, which were in Chicago,” said Bengard. The new boilers also have scale sensors on the inside to alert the operations team to any buildup of scale that might require cleaning.
“The new air systems also are fairly unique,” Bengard said. “They utilize a Hunt Air Fanwall system. A typical air-handling unit has one large centrifugal type fan. These have an array of nine or more, so if one fan fails the whole system isn’t down. That redundancy aspect is fantastic for hospitals. It has the same performance as a centrifugal fan, but if one fan fails in a fanwall, you can block that off in minutes if you don’t have a replacement and your system won’t know its missing,” he explained.
SSM also invested in two, 850-ton chillers and a 125-ton chiller. “We can operate just the smaller one in the winter to produce the chilled air we need for operating rooms,” Gratton said.
“They selected the most efficient chillers they could. They are probably twice as efficient as what they had [in the old hospital] in Kirkwood,” Bengard said
“We were very thoughtful in how we spent money to make health care more effective,” said Porter. “We’re essentially retooling the hospital stock to increase efficiency and increase effectiveness. Our aim is to deliver the right care at the right time in the right place,” he said.