Having recently been involved in the planning of several international hospitals, I have become acutely aware of the need for a “primer” on patient room design. While most of the countries in which I have been working have a well established health system, their perspective of the patient environment is frighteningly medieval. There is little hesitation in designing multi-bed wards, hygiene is completely overlooked and the patient family is seen as nothing more than a nuisance. How wrong they are! Single bedded rooms reduce transmission of hospital-based infections, most of which are transmitted by staff members who do not practice proper infection control through hygiene and the family has become an integral part of the patient care model. Family involvement speeds recovery and reduces staffing needs thereby reducing hospital overhead.

I will devote my next few blogs to the design and construction of patient rooms. I invite your thoughts and hope you enjoy them.

Glamorous hotel chambers are in line with another trend that has been quietly percolating for the past 15 years or so:  doctors in the U.S. who refuse to participate in health insurance provider panels. These doctors have decided that rather than accept measly payments and kowtow to the demands of insurance companies to treat hordes of patients, they will cater to patients who can pay for medical services out of their own pockets. They seek a more elite and affluent patient base, hoping for a better pay-off than a see-all-comers approach can yield.

These luxury services need not be limited to VIP’s.  Hospitals such as Hackensack University Medical Center, a premier teaching hospital in northern New Jersey, has introduced concierge food service to all patients.  A menu, prepared by the medical and nutrition staff, is personalized to fit each patients health restrictions.  Patients dial a concierge desk when they are ready for their food and a porter in bow-tie and black vest delivers their order to their room within 15 minutes.

Early reports indicate an increase in patient satisfaction and a reduction in overhead costs to the hospital.  Patients are empowered to choose what they want to eat whenever they are hungry, and their food is always fresh.  This removes the stigma of cold “hospital food” in a plastic tray.  For the hospital’s bottom line, food waste is reduced because patients do not order what they won’t eat.  Additionally, staffing this delivery system is less intense than standard distribution.  Not every patient needs to receive their food within the same 30 minutes.  delivery is more evenly disseminated throughout the day to fit patients’ personal rhythms, and thus requires fewer FTE’s.

On one of my current global projects, I’ve added a luxury wing to a hospital that I’m building in the Middle East. The extra costs of building the luxurious floor are worthwhile to the hospital’s owners, who recognize the value of catering to patients’ wishes. Discriminating consumers appreciate excellent medical care delivered in deluxe accommodations, and they are willing to pay the price it demands.

As I’ve said before, hospitals are businesses that need to turn a profit. Adding services to enhance customer satisfaction is a smart move, because satisfied customers become repeat customers and sources of new referrals. There will always be people who can afford to pay more for better service; a hospital that can attract those people will only benefit.

University of Bristol researchers examined the books of hospitals that had merged in the late 1990’s and early 2000’s. During that time period, half of the acute hospitals in England consolidated. The researchers learned that the hospitals’ deficits actually grew post-merger! Four years after the mergers, hospital admissions typically had fallen by about 10 percent, and waits for elective treatment had been lengthened. Neither quality of care nor profit earning had improved.

The hospital executives and health plan administrators who designed these mergers surely had something else in mind when they decided to go through costly and complicated mergers. The main reasons they offered the researchers were to streamline facility use, provide better patient care, and increase earnings. Quite the opposite occurred.

Instead of merging, hospitals can strengthen their financial health and patient care by assessing their existing facilities to ensure that they are used to capacity. Updating the building’s design to meet current medical standards improves the hospital’s appeal. Underused facilities can be bolstered by acquiring physician practices and integrating them into the hospitals’ offerings. Hospitals can maximize use of their facilities by intensifying marketing efforts to target populations.

Every business, including healthcare, requires sharp strategizing and constant fine-tuning. Planning the best way to use its facilities can help a hospital stay ahead of the game.

Millions of people in third world nations have almost no access to health care facilities. Where facilities exist, they are often concentrated in the major cities, leaving rural residents to flounder.  About half the population of several African countries lacks access to health care.

The United States government’s efforts to coordinate with developing countries to enrich their healthcare provision are admirable. Donors, both corporate and individual, work with poor countries to expand their existing systems and use resources effectively.

Good health practices need proper facilities. Just like countries with advanced health care practices, developing countries have to think about minimizing the cost of service delivery, as well as maximizing their resources by building facilities intelligently.  The immediacy of the needs must inform the practicality of implementation.

Several months ago I blogged about the use of prefabricated health facilities.  The idea is simple – build a hospital in modular components  in a controlled environment, ship it to where it is needed, and assemble the prefabricated components on site.  Simultaneously, it is as advanced as assembling a space station and as simple as creating a trailer park.  The possibilities are endless and locations limitless.  We can “insert” healthcare facilities into the jungles of South America, the deserts of Africa or the mountains of Asia.   Shipped as a package together with supplies and medications, they can be providing much needed care within months.

In 2011, 76 million of America’s surviving Baby Boomers began to turn 65. Healthcare advances have increased life expectancy to age 75.6 for men, and 80.8 for women. Medicare, which covered 47.4 million seniors in 2010, will cover 78 million people in 2030. The massive numbers of aging Americans, combined with their extended life expectancy, equals a growing strain on hospitals.

Many Americans reach a ripe old age without needing significant hospital visits, but statistically, an older population has greater healthcare needs. Based on sheer numbers, hospitals can anticipate a rising need for their services. They will need to provide more outpatient procedures, more inpatient stays, and more emergency room treatments. They will have to have more staff, more supplies, and more available rooms.

Forward-thinking hospitals should be planning now for the near future. Hospitals that want to respond to the needs of their patients with the highest level of care have to construct the right facilities. The great wave of Baby Boomers is an informed group that demands proper treatment. In order to become the first choice of patients, hospitals need comfortable, spacious, hygienic and updated rooms.

Healthcare is a business, and only profitable healthcare institutions can give their patients what they need. Nisan Gertz Associates provides facility related solutions that reflect its understanding of the business of healthcare. Expanding sensibly, with intelligent design and construction, will give hospitals the edge they need to face the future of healthcare.  Especially during this financially challenging period, hospitals cannot afford to invest in capital projects which will not provide proper returns.

Wishing you a happy, healthy and profitable 2012!

The first good idea is to increase spending. Currently, only 1% of India’s gross domestic product is spent on healthcare. Governments the world over should prioritize healthcare, and put their money where their mouths are by increasing payments to the healthcare industry.  Governments are established to lead and care for citizens; maintaining citizens’ good health is crucial to their mission.  The health system is an excellent repository for the governments’ tax revenues.

Spending more on primary care is also wise. Widely championed by medical professionals, the revolutionary concept of preventing disease instead of grappling with advanced illnesses should be adopted by every nation. Basic check-ups and health education go a long way, toward a healthier population and reduced healthcare payments.

Like the article’s author, I appreciate the money-saving notion of buying drugs in bulk. In India, as in the U.S., out-of-pocket spending on prescription drugs takes a hefty bite out of people’s incomes. Governments that buy large quantities of drugs are able to provide free or low-price medications to their citizens. Granted, this step would require the government to increase its healthcare expenditures, but in a thrifty, economical manner.

Every nation can learn to improve its healthcare habits. Spending money on healthcare in a thought-out manner will lead to improved financial and physical health.  Even more important is for governments to start exploring more innovative ways to deliver health care.  Technology has advanced to the point where care can be provided from miles away and even from another hemisphere. Hospital design and construction anywhere in the world should include cutting-edge technologies that bring patients the best care.

Star Health Network is a US based company that is providing US caliber care to India’s population.  In the simplest of terms, they are a “virtual” Doctors Without Borders.  They provide Western expertise through doctor-to-patient and doctor-to-doctor consultations.  Their proprietary web-based interfaces, distance diagnostics and clinical trials use the best that technology has to offer.

Governments, NGO’s and health systems can learn from companies like Star Health and embrace the use of cyberspace in patient care, diagnostics and treatments.

It seems that some Americans take exception to the program’s stifling requirements. One of the dissenters’ complaints is about the demand for across-the-board coverage, meaning everyone must buy a health care policy. President Obama has explained that in order to offset the cost of covering individuals with pre-existing disorders, young and healthy people have to contribute to insurers’ costs by paying premiums for services they are unlikely to touch. His rationale fails to persuade many young and healthy people to buy health insurance.

The health care reform calls on individuals to purchase a minimum level of health insurance, which many find unsatisfactory. A low-level insurance package could cost several thousand dollars a year, and cover little beyond a portion of doctors’ visits and hospital stays. Low cost plans usually don’t cover prescription drugs, and they often pay a limited amount for hospital visits. By and large, insurance holders are restricted to choosing from a narrow number of in-network doctors. Furthermore, insurance plans use disincentives to prevent their customers from visiting pricey specialists.

Opponents of President Obama’s plan don’t want to be forced to buy anything, let alone expensive healthcare plans that give little bang for their buck. They realize that bargain basement insurance policies won’t help them if they’re hit with a biggie like cancer or heart disease. Serious illnesses demand extensive health services and tremendous outlays of money; the less expensive insurance packages that individuals can afford are unlikely to give sick people the treatments they need.

The Supreme Court will decide whether the reforms tread on Constitutional rights by forcing Americans to buy a commercial product. By June 2012, individuals will know whether they have to buy a product that might not be worth the investment.

Universal healthcare should not be a burden to U.S. citizens, and it should not cost exponentially more for those who don’t work for conventional employers. Self-employed people, unemployed people, and independent contractors should not be forced to buy expensive policies with few benefits, while those who work for companies take advantage of discounted, comprehensive policies.

Just as I broadened my healthcare perspective when I began working in other parts of the world, U.S. law makers should look to other countries as models of REAL universal healthcare. European and Scandinavian countries, Canada and Israel, have all figured out how to offer more or less equal healthcare to all its citizens, without placing such an onerous burden on some sectors of the population. A democratic country like the U.S. should not have discriminatory healthcare policies.

In this recently published article, the WSJ focuses our attention on a major global issue.  We are introducing new and desperately needed healthcare facilities to maturing populaces in India, The Middle East, Eastern Europe, Latin America and Asia.  But, what is being done to improve the existing  healthcare and hospital facilities and infrastructure?  Simple operational protocols and procedural changes could save lives, immediately.  These require far less investment than new construction and can be implemented in less time.

How can we, as designers, constructors, developers and operators promote awareness for improved care delivery within existing facilities?

It’s primary drawback is its lack of facilities.  Only 62 years old, Israel has 38 hospitals containing 13,000 licensed beds.  This past winter, at the height of the flu season, occupancy reached 200% and prompted much criticism of the government.  The Ministry of Health responded with the promises of 10 Urgent Care Centers and an additional 1,300 beds over 10 years.  Truly a case of treating a gunshot wound with an aspirin.

While service is generally of good quality, access to service providers is not aligned with the demographic distribution of this small but overpopulated country.  Israel is 8,630 sq. miles (roughly the size of New Jersey) with a population of 7.7 million people.  57% of its population live in the center of the country.  A disproportionate 84% of its hospitals are located in this center portion.  They are mostly clustered around Tel Aviv and Jerusalem and sometimes 45 minutes by ambulance from large population centers.  Even more disconcerting, the periphery of the country can be more than 90 minutes from the nearest hospital.

Israel’s first step to healthcare realignment is to assess the quality and access of care throughout the country.  The system must be viewed and analyzed as a single organism.  What is needed is a process similar to New York’s “Berger” Commission on Health Care Facilities in the 21st Century.

The commission is self described as “a broad-based, non-partisan panel created by former Governor Pataki and the New York State Legislature to undertake a rational, independent review of health care capacity and resources in New York State. It was created to ensure that the regional and local supply of hospital and nursing home facilities is best configured to appropriately respond to community needs for high-quality, affordable and accessible care, with meaningful efficiencies in delivery and financing that promote infrastructure stability.”

I predict that a similar study in Israel will call for a realignment of facility locations.  Terems (Israel’s version of Urgent Care Centers) should be strategically located to fill service gaps.  They will extend the reach of the system by providing primary acute care throughout the country.  Next, small community style hospitals should be introduced into the system to allow quicker access to broader medical care,  providing secondary level care.  Lastly, new Medical Centers should be introduced and placed BETWEEN cities.  These will provide specialized, tertiary and level one trauma care.  These three components will complete a web, making healthcare accessible throughout the country.

The days of tertiary medical facilities being located in metropolitan centers have passed.  Traffic patterns make access to the city centers difficult. Realistically,  these hospitals can only serve one city, instead of one main city and many smaller surrounding ones.  Israel must look toward the future and assess how and where its population will grow.  It will then find that the most natural and logical locations are between cities with triangulated catchment areas.

These solutions are fairly simple and partially intuitive.  The challenge is getting government to follow the simple path and think intuitively.

The Ashdod hospital will be the first new hospital in Israel in 36 years.  That is longer than half of the very existence of the state, itself.  Even more precedential, it is being touted as the first development award of a public health facility to a non-governmental development consortium.

This deal is similar to a PPP or PFI, but it falls short in several areas.  Private Finance Initiative (PFI), also termed Public Private Partnerships (PPP or P3), is a financing structure whereby a consortium of private companies partner with local government entities. The consortium is comprised of private sector financial, design, construction and facility operations partners who provide the various components of the project. Together, they deliver a completed product which is occupied/utilized by the local government agency and is paid for as an ongoing operational expenditure. Most PFI structures are formulated with a pay-down period (through capital expenditures) and are owned by the local authority at the end of said period (typically 30 years).

PFI funding initiatives are commonly utilized in Europe and Canada for infrastructure projects such as toll roads and energy production and waste management plants. They are also being implemented in schools, hospitals and government buildings. The United States has shown limited interest in this financial structure, for toll roads in the states of Texas and New Jersey.  It is not as common in public healthcare because most hospitals are privately owned as non-profit or for-profit entities.  State or City owned hospitals generally finance their projects through special issue bonds or direct government funding.

PPP’s and PFI’s are desirable to private companies, because they allow them to  invest in government projects. In return for their investment, the government guarantees them a high fixed rate of returns. Typically, the government takes ownership of the project after thirty years’ time. Until that time, the investors continue to receive regular income as interest repaid on their investment.

The Israeli healthcare system is a socialized service similar to Canada or England.  However, it provides a much higher quality of service than most other countries.  Its primary drawback is its lack of facilities.  Only 62 years old, Israel has 38 hospitals containing 13,000 licensed beds.  This past winter, at the height of the flu season, occupancy reached 200% and prompted much criticism of the government.  The Ministry of Health responded with the promises of 10 Urgent Care Centers and an additional 1,300 beds over 10 years.  Truly a case of treating a gunshot wound with an aspirin.

The government does not have the funding sources to expand existing hospitals or to build new ones.  It does have the funding and accepts the responsibility, however, to provide healthcare if these facilities would somehow materialize.  Enter PFI/PPP financing mechanism.  This would be the perfect solution for such a short-term fiscal challenge.  It is a system yet to be understood or accessed by the Israeli government.  Surprising, considering that the prime minister, Bibi Netanyahu has a Masters degree from MIT’s Sloan School of Management.

The key to a successful PPP/PFI process is the tender documents.  They need to be prepared by a knowledgeable government and submitted responses must be from experienced consortiums.  This is where the Ashdod project fell short of its mark.  The tender was not issued as a true PPP/PFI and the responses came from an assortment of individual players and not a consortium or combination of all of them.  Respondents included Clalit Health services and Africa-Israel, the country’s largest commercial developer. Ultimately, the government awarded the project to itself.  A true balagan (Hebrew for chaos), if ever there was one.

What next?  My next blog will address solutions for Israel’s healthcare system.  It is an excellent study in the expansion and advancement of a truly successful socialized healthcare system.  Take note, President Obama.

Additional PPP/PFI Resources:

Public Private Partnerships (PPP) Bulletin
Private Participation in Infrastructure (PPI) Project Database
The Canadian Council for Public Private Parterships
Private sector industry body for PFI/PPP
Federal Highways Administration – PPP website
International Project Finance Association
Community Health Partnerships – delivery agency for health and local authority services