CRITICAL ACCESS HOSPITAL OF THE FUTURELanglade Hospital

A MIRON

CONSTRU

CTION CASE STU

DY

“I really do believe we have a facility for the future …

The most compelling reasons for a new hospital revolve around ways it will allow improved services for patients

and the community well into the future.”DAVE SCHNEIDER

CEO of Langlade Hospital

CHALLENGES FACING A RURAL, CRITICAL ACCESS HOSPITAL

In 2008, Langlade Hospital, a rural, critical access hospital located in Antigo, Wisconsin, differed little from other rural hospitals throughout the country. It faced many of the same challenges as its peers:

Rural residents are older, have lower incomes, are more apt to be uninsured, and are more likely to suffer from chronic diseases.

Rural healthcare workers are aging and nearer retirement age than their urban counterparts. The growing shortage of health workers may have a greater impact on rural facilities.

Access issues, such as longer travel distances and lack of reliable transportation, can delay treatment by rural patients, aggravating health problems and leading to more expensive care when received.

Rural hospitals are smaller—nearly half have 25 or fewer beds— but must still maintain a broad range of basic services to meet the needs of their communities. Costs per case tend to be higher, because fixed expenses are spread over fewer patients.

Insufficient access to capital affects the ability of rural hospitals to modernize facilities and acquire new technologies to improve operational effectiveness. Rural hospitals lag their urban counterparts in adoption of health information technology.

Source: American Hospital Association. The opportunities and challenges for rural hospitals in an era of health reform. Trendwatch, April 2011. http://www.aha.org/aha/trendwatch/2011/11apr-tw-rural.pdf

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VISION FOR THE CRITICAL ACCESS HOSPITAL OF THE FUTUREIn 2009, Dave Schneider, CEO of Langlade Hospital, engaged Sg2, a national expert in healthcare planning to plan for a replacement hospital that would meet the needs of the 21st century patient and physician. Dr. Manuel Hernandez, an Sg2 director who guided the work, said the goal was to create a “facility of the future” which could be very different from the traditional hospital models of the past. Sg2 helped lay the groundwork for growth forecasts for the hospital and region over the next 10 years. With this information in hand, Religious Hospitallers of St. Joseph, which operates the hospital, and Aspirus, a partner in the facility, approved moving forward with funding the design and construction of a new replacement hospital. Dave Schneider then asked the newly formed construction and design team to “design and construct the critical access hospital of the future.” From the beginning, Dave understood this project would be different. He asked the team to re-imagine healthcare and the connection the team could have with the local community. Miron Construction Co., Inc. was hired as the design-build contractor for the new hospital. Miron and the project owners brought Wisconsin-based Eppstein Uhen Architects onto the team. With the contractor and architect in place, the team wasted little time in getting people involved to get the process rolling.

THE PASTRespecting history was also extremely important

to the hospital. It was originally founded by the

Religious Hospitallers of St. Joseph, a Catholic

healthcare organization established in France in

the 1600s. Today, three nuns remain in residence

at the hospital. Throughout the planning of the

new facility, Sister Dolores Demulling reinforced

the need to honor the history of the hospital,

a passion that resulted in innovative art and

architectural solutions that incorporate the

original stain glass chapel windows and cherry

wood details created from an original cherry tree

cut down to make way for the new hospital.

BACKGROUND

While these challenges are not unique, Langlade Hospital wanted to blaze a new path. Antigo, once a busy lumber town (1890-1920), had constructed a 100-bed hospital in 1933. Like many rural communities, the hospital had not been renovated for many years. The former 1930s-built Langlade Hospital was 110,000 square feet of sprawled-out space, unyielding to today’s healthcare needs.

RETHINKING THE DELIVERY OF HEALTHCARE

The new 23-bed replacement hospital has dissolved the departmental silos of the old facility by involving all 550 employees (through Innovation Teams) in the innovation and design process. The new Langlade Critical Access Hospital was designed with the patient experience in mind. In fact, many patients feel like guests at an upscale hotel rather than patients at a high-tech healthcare facility. Every decision made throughout the design and construction process was based on what was best for the patient, and the hospital’s administration team definitely drove that home. Innovation was at the heart of this project. The team, comprised of hospital staff, administrators, care providers and patients, along with members of the design and construction team, were tasked with implementing innovative features and processes throughout the project.

Ultimately, twenty-five innovation teams (iTeams) took on specific jobs, getting involved in everything from process improvement to move planning. They met biweekly to analyze the hospital’s processes and identify issues, opportunities and best practices, all while incorporating experience-based design and lean principles. It was their opinions that shaped the resulting facility—the hospital of the future.

This integrated planning methodology created more than 90 healthcare innovations, 100+ hospital future-state value-stream maps, and best-practice evidence-based design applications.

One challenge did surface in the form of staff members trained to do things a certain way. The average employee’s tenure at Langlade Hospital is 26 years. Most worked with the same team, in the same environment, and delivered the same model of care for years, which can make change difficult. Although the teams consistently delivered exceptional quality and received high patient satisfaction scores in their individual departments, the hospital’s leadership wanted to break down existing department boundaries and integrate a culture of collaboration and space flexibility. Individuals were urged to break out of their “always-done-it” attitude to a “wouldn’t-it-be-great-if ” way of envisioning the future to create “win-win” departmental layouts.Team members were encouraged to not simply rely on what they’d always done, or what the competition was doing, but instead look at things from a completely new perspective. The team explored other facilities and industries as benchmarks: Anthropologie for retail, Apple for technology and Southwest for travel. They discovered that the success of each of these companies relies on understanding the emotional connections users develop with their experiences. By standardizing that process, Langlade could design how the experience with patients would go and how they would feel connecting with a provider before it ever happened. With a new culture centered on the ideal patient experience, the team set out to improve each point-of-contact experience with the patients, from registration to release.

Upon completion, the building was ahead of schedule by 60 days and nearly one million dollars under budget.

COMMUNICATION,BUDGET AND SCHEDULE

Continuous monitoring of the project

budget and schedule during all phases

of the project, and real-time tracking and

dialog between team members allowed

the project to be adjusted quickly and avoid

significant value engineering.

The project schedule was delayed

at several points during the pre-design

and design development phase to ensure

that new operational concepts developing

in the Innovation Teams could be tested,

refined, and approved before finalizing

the building design.

DESIGN AND INNOVATION TEAMS - REIMAGINE

The design phase was the project’s most challenging, but also the most rewarding. Though there were many needs the new design was required to meet, the hospital was encouraged to reinvent itself into a more efficient organization, but in an extremely fast-tracked time frame. The process of reinvention typically takes a great deal of time; however, the iTeam process and efficient decision-making made this swift transition possible. What normally takes four or five years was condensed into an 18-month period. Ultimately, the new design is more compact, creating operational efficiencies in what is also a very energy-efficient facility. More than 90 major operational changes were executed. On May 25, 2012 Langlade Hospital opened the doors to a new 21st Century facility that honors the past, empowers the present, and is ready to embrace the future.

THE NEW LANGLADE HOSPITAL WAS DESIGNED AND BUILT TO FULFILL ITS VISION:

Maximize patient safety, comfort, security and privacy, improving the patient experience from front door to point of care.

Enhance the retention and recruitment of physicians, providers and staff.

Boost operational and staffing efficiency and reduce ongoing operating costs, creating the shortest distance between user and need.

Increase flexibility in order to respond rapidly to daily and evolving healthcare demands.

Incorporate environmentally-friendly design features, systems and materials.

Establish Langlade Hospital as the provider of choice for state-of-the-art health services in its area.

LANGLADE INNOVATION TEAMSSurgery/Endo

Inpatient Rooms

Education/Conference

Medical Staff Lounge

Office Space

Food Service/Retail/Menu

Registration

Medical Records

ED/Urgent Care

Chapel

St. Joseph’s Building

Cancer Treatment

Rehab/Wellness/Retail

General Clinic

Sleep Lab/ Neuro Service

Materials Handling

Injection/Infusion

Sustainability

Overall Move

Brand/Wayfinding/Aesthetics

Discharge Process/Instruction

Pharmacy

Safety & Security

Housekeeping

Lab

UNIQUE DESIGN FEATURES

ADJACENCIES A great deal of design time was spent discussing adjacencies of departments within the facility. � The emergency department, for example, was placed next to surgery, to support

instances of emergency surgery and overflow. It was also located near the imaging department in order to cut down on foot traffic throughout the facility.

FLEXIBILITY In order to allow the hospital to operate in a lean manner, while not only serving the needs of patients today but into the future, many spaces were designed and constructed with flexibility in mind. The new flex plan ultimately allowed for substantial upfront savings. � Surgical Services (inpatient/outpatient) includes three Operating Rooms (ORs)

at 600 square feet each to accommodate future innovations and equipment.

� Operating Room (OR) and Emergency Department (ED) prep and recovery space will be shared with ED/WIC (Walk-in-Clinic); six flex rooms will be shared with surgery in the morning and with ED in the afternoon.

� Both the emergency area and surgery pre- and post-op areas can expand or contract to meet space needs.

� Although the facility was constructed as a 23-bed hospital, it can increase to 25 if necessary. Included in those 23 rooms are three LDRP (Labor Delivery Recovery Post-Partum rooms) with two swing beds allowing flexibility to five LDRPs and postpartum beds, plus two ICU rooms (instead of four, as housed in the old hospital). Additional monitoring equipment was placed in two of the medical surgery rooms to allow for these spaces to be converted, when necessary.

� The labor delivery area can also flex into medical surgery rooms.

PROCESS EFFICIENCIES

� Patients can find assistance within seconds. With the advances in technology, caregiver photos, hospital information and call systems appear right on patient TV screens. Remote controls also allow them to operate window blinds and room lights from the bed.

� Online personal records allow quick access for doctors to private medical information.

� A centralized registration desk, rather than separate registration desks for each department.

� An interior designed with decentralized nursing stations/pods allow for quick connection to patient and family needs.

� Consolidated three nursing units into a single inpatient clinic for Critical, Medical, Surgical and OB patients.

� ‘Front of house’ public areas and ‘back of house’ corridors and rooms only accessible to staff members. This creates uncluttered and extremely efficient traffic flow and keeps patient transfers out of public traffic areas.

� Streamlined 10 points of scheduling to 2 (hospital & clinic) – predetermined times are based on patient schedules, not those of the hospital system.

� Paperless record system throughout the new hospital allows for quick sharing of information and efficient use of medical records.

� New material handling process using Kan Ban Lean principals allows for more efficient use of resources. Easy to locate supplies are placed in the same location for each patient room, reducing the “find” time.

� Efficient use of every square foot of space and logical and intuitive wayfinding for optimal patient satisfaction.

DESIGN FOR THE FUTURE

� The hospital has its own corridor dedicated to women’s services, not something you typically see in a facility of this size.

� All three birthing rooms have been set up with whirlpools to accommodate water births.

� The use of boom technology in the ICU (it’s typically only used in surgical areas).

� Langlade saw a big divide between older generations and younger, tech-savvy patients. The younger generations wanted to see more things automated and self-controlled, such as registration and the nurse-call system, while the older generation opposed those types of changes. The team’s solution to this issue was to build a simplified system with the ability to add and expand functionality in the future as more patients become comfortable with technology.

� In the event of a catastrophe, such as a chemical spill, the facility has its own decontamination room with showers and a system that pumps water into a specialized decontamination tank. Most hospitals utilize temporary tents in these situations, in which they are unable to keep contaminated runoff from entering nearby storm water systems.

� Spa-like ambiance—warm, pleasant and comfortable surrounds set the stage for a unique experience. Customized vinyl wall coverings with inspirational sayings and bold imagery make the facility feel a little more like home.

� Patients hospitalized overnight find rooms restful and well-appointed. Each patient room has double-wide doors, a tiled private bathroom (with walk-in shower) that is only four feet from the bed and a pull-out sleeper sofa for family members.

� Unique family spaces with soft seating, hospitality services and games make guests more comfortable and their stay more relaxing.

� Welcome Center & Education Café – Coordination of care is driven for the patient through a comprehensive navigation team from the very first day of arrival. Consultation, lab, wellness, education and online updates are completed for patients. A unique health education process also means personal health information is updated for patients online, including reminders. Also, families no longer have to wonder where to go. Pre-visit tours are given and questions are answered.

� An interior courtyard provides green space for employees and visitors while also flooding what would otherwise be interior space with natural light.

� Emergency Services/Walk-In-Clinic with central registration for hospital and clinic.

� Laboratory services – hematology, chemistry, microbiology and blood bank.

� Imaging (general X-ray, fluoroscopy, CT scan, MRI, nuclear medicine, imaging reading services, women’s imaging center, mammography, bone densitometry, stereotaxic breast biopsy) with plans for expansion.

� SportsFitTM and Well Fit Center services include physical therapy, occupational therapy, speech therapy, cardiopulmonary rehabilitation and inpatient pharmacy services.

� New and improved dietary services include a spoken menu for patients (bedside patient ordering) and café with healthy choices for outpatients and visitors.

� Three Sisters Café features comfortable seating in a pleasing environment. Grab-and-go food is available along with numerous other delicious menu selections. Visitors can relax with a cup of coffee as they check their email with free Wi-Fi Internet service.

� Conference center for internal and public meetings, located off the lobby.

� Chapel to reinforce the hospital ’s mission and a gift shop for visitors.

� Future expansion for 6-10 new providers.

� New cardio-pulmonary area providing a central area for patient diagnostic testing.

� Private pre-operative room for a personalized surgical experience.

HIGHLIGHTS

C5 Process

At Miron Construction Co., Inc. the C5 Process is much more than a way of delivering services. It is a philosophy-a different way of thinking. This philosophy demands a deep understanding of who our clients are and what is most important them-we call this DNA.

In order for the Langlade Replacement Hospital to realize its full potential, the Hospital’s unique needs became the focal point of the entire project. Ultimately, the ability to CAPTURE Langlade’s unique needs, CREATE customized solutions, and CONSTRUCT tangible results, with a team that consistently COMMUNICATED and CONFIRMED their unique drivers is what helped ensure success. The Project Team relied on the following tools to achieve this success.

INFORMATIONALPRODUCT OR SERVICE

Ideal Experience

Experience Ecology

PHYSICALSPACE

BEHAVIORALHUMAN INTERACTION

Evidenced-Based Design From the beginning of the project, the team realized that there is an urgent need to address the inherent problems in the Langlade operational planning efforts that lead to staff injuries and hospital-acquired infections, medical errors, operational failures, and waste. Project drivers, focused on improving the physical environment, included:� Improving care team health and

safety� Increasing effectiveness

in providing care � Reducing errors � Increasing patient and

practitioner satisfaction (increasing market share and retention)

It also became increasingly clear that efforts to improve the physical environment alone were not likely to help achieve project goals without a complementary shift in work practices. Since the hospital physical plant was more than 80 years old, operational models were constrained by the facility. It was important to identify core systemic and facility design factors that lead to failures, inefficiencies and non-value added

activities. Once understood, new, unique solutions that addressed the problems within the context of the culture changes and evolving methods of care were created. Examples include identifying operational and system problems that impact staff effectiveness and productivity (such as interruptions, transfers, lack of information) and develop design and care models (e.g., acuity-adaptable rooms) that effectively address these problems. More than 100 value stream maps were created in the future state to determine best practices and design theories, including:� Identified operational and system

problems that impacted staff effectiveness and productivity (such as interruptions, transfers, lack of information).

� Created new design and care models (e.g. acuity-adaptable rooms, flex suites, pre/post suites).

� Identified steps through the iTeam process to promote the Langlade service culture parallel to design changes to ensure effectiveness and acceptance for new innovations.

� Used Kan Ban systems for material management processes and frequently used supplies in relation to location of key spaces (patient room, nurse work space, location of equipment and supplies) with the goal of minimizing walking distances and number of trips. (See photo above right)

� Through the design of the new hospital, provided opportunities for spontaneous and planned interactions within the healthcare team within collaborative areas.

� Provided spaces throughout the hospital for families and patients to be effectively included in the healthcare team.

� Installed ceiling lifts in all patient rooms to reduce staff back injuries along with instituting a no-manual lift policy.

� Understood sources of infection and injury to staff (air, contact, and bloodborne) throughout design and construction.

� Instituted multiple measures to reduce noise stress among nurses (e.g. improving acoustic conditions on the nursing unit, education, and awareness programs).

Building Information Modeling (BIM) We created near photorealistic representations of many critical spaces early in the design phase. This enabled the Project Innovation Teams to visualize the design concepts and provide more meaningful feedback and guidance to the design team.  As we have seen with many other projects since, this, coupled with Rapid Access Prototyping, has been an invaluable service to our clients providing a ‘no surprises’ end product.

Rapid Access Prototyping Reverse Outcome Prototyping or ‘RAP’ was used extensively throughout the Langlade Hospital pre-construction process. This tool replaced the traditional methods of 'mocking-up' areas for individuals to interact within. Traditional modeling (or mock-up) efforts are inflexible and rigid. They incorporate only the current status allowing for little interaction or change by the end user. Rapid Access Prototyping allows staff participants and end users the opportunity to interact within the context of the proposed area (or room) while making 'real-time' changes to the overall space–all in the future state processes. As a result, better outcomes are created for every stakeholder allowing for rapid changes to proposed areas during the design process.

Innovation Team Members–physicians, clinical assistants, nurses and patients co-created the new, ideal patient areas through RAP, including: in-patient rooms, registration, operating rooms and LDRP Birthing Suites.

Both financial and emotional savings occurred through the use of Rapid Access Prototyping. True to the spirit and mission of the project, the tool improved the quality of care by offering a better understanding of patient and staff flows, efficiencies and, at the same time, reduced construction costs. In the end, more than 90 changes were made through the RAP process, which in the past, would have been missed, causing undue change orders and unneeded expense.

Langlade Hospital - Operating Room Virtual Model

Rapid Access Prototyping - Patient Room

LANGLADE HOSPITAL'S SUSTAINABLE CHARTER Langlade Hospital created a sustainable charter with the aim of balancing health care wellness that benefits patients, families and employees, while improving the quality of life for their communities and conserving the world’s natural resources. With a focus on continuous improvement, the hospital seeks to increase economic value (Prosperity), to engage social improvement programs that have real impact and help build healthy communities (People) and to uphold responsible stewardship of the environment (Planet).

To fulfill the goals stated in this Sustainability Charter, Langlade established the following guiding principles:

� Demonstrate institutional practices that promote and exemplify sustainability, including measures to increase efficiency and use of renewable resources, and to decrease production of waste and hazardous materials, both in the hospital ’s own operations and in those of its suppliers.

� Promote health, productivity and safety of the hospital community through programming, design and connection to our stakeholders.

� Enhance the health of hospitals ecosystems and increase the diversity of native species.

� Develop planning tools to enable comparative analysis of sustainability implications and to support long-term economically, environmentally and socially-responsible decision making.

� Encourage environmental inquiry and institutional learning throughout the hospital community.

� Establish indicators for sustainability that will enable monitoring, reporting, and continuous improvement.

� Exceed the needs of our patients and customers with innovative solutions that drive sustainable growth.

� Recognize that our planning and actions do not stop at the hospital boundary, and as a result aggressively partner with the City of Antigo, Langlade County, and the businesses, industries, and agencies that in aggregate define the extended Langlade Hospital neighborhood.

ENERGY SAVINGS

Through energy modeling, high efficiency building systems, and a high performance building envelope, the project team:

Achieved a 36.7% decrease in energy consumption versus a comparable Focus on Energy baseline project

Resulting energy cost savings of $122,125 annually versus a comparable Focus on Energy baseline project

Recognized $102,221 in rebates from Focus on Energy

GREEN FEATURES

� Repurposing of existing building site� Reclaimed stain glass windows � On-site storm water bioretention� Zero CFC-based refrigerants� LED lighting with smart controls� Nature trail restoration

PRESERVING THE PAST

A 110-year old cherry tree stood where the hospital addition was planned.

To preserve the past and the heritage of Langlade Hospital, Miron used the

wood from the cherry tree to build furniture, and also for the many cherry

wood architectural features throughout the hospital.

Langlade Hospital - Cherry Wood Furniture in Lobby

MEASURED RESULTS Innovation & Experience – The success of the hospital of the future is measured through personal interaction and operational performance. During the planning and design of the new hospital, project team performance was measured based on:

EXPERIENCE / OPERATIONS / SPACE

-50% Reduced operating room sterilization time by 50%

+30% Increased surgical pre-operative education by 30%

+6%  Communication with doctors increased by 6%

+7 %  Overall HCAHPS Loyalty+ Rating increased by 7%

-60% Compressed registration time by 60% through care navigators and a kiosk-guided patient registration process

+17% Increased patient satisfaction with pain management by 17%

-35% Reduced material handling process time by 35%

+14 % Enhanced staff responsiveness by 14%

-14 % Decreased patient falls by 14% due to a 70% reduction in the distance between the patients and their restrooms

+20% Increased patient satisfaction with communication about medications by 20%

Go behind the scenes and watch footage of innovation in the making!

Langlade Hospital Innovation

youtu.be/Ls0Oi91isHM

Langlade Hospital - Innovating Patient Care

youtu.be/ifcl0CjZPy4

CRITICAL ACCESS HOSPITAL OF THE FUTURELanglade Hospital Replacement Critical Access Hospital

It is apparent that incorporating the latest in healthcare innovation, advanced technologies and functional work space that position caregivers closer to patients, who would enjoy a more comfortable hospital experience, were driving factors in the design of the facility. Dave Schneider put it best when he said, “I really do believe we have a facility for the future … The most compelling reasons for a new hospital revolve around ways it will allow improved services to patients and the community well into the future.” Not only does the new facility establish state-of-the-art services in the hospital’s patient service area, the changes also mean that the people they serve will enjoy the most advanced and modern facilities in the area.

Dave further explained, “Our new hospital project has positioned our organization well for the future. We have created an environment that really enhances the patient experience while maximizing patient safety, privacy and comfort. We engaged in a design process that was much lengthier than usual because, with every decision made, we considered the impact of the decision on the patient. Every innovative feature in our new facility, and there are many, reflects our intensive efforts to assure that the new Langlade Hospital is truly patient-centered.”

DELIVERY METHOD Design-Build

TOTAL PROJECT COST $47,000,000

PROJECT SIZE 94,705 SF

CONSTRUCTION DURATION 19 months

OWNER

Langlade Hospital 112 East Fifth Street

Antigo, WI

David Schneider dschneid@langhosp.org

715.623.9210

CONTRACTORMiron Construction Co., Inc. Neenah, WI

920.969.7000

Project Manager: Heather Stoffel heather.stoffel@miron-construction.com

Project Superintendent: Jess White

ARCHITECTEppstein Uhen Architects Milwaukee, WI

414.271.5350

Kristen Dufek kristind@eua.com

Scott Uhen scottu@eua.com

ENGINEERHennemen (all MEP) Madison, WI 608.833.7000

Pierce (structural) Madison, WI 608.256.7304

CREDITS

Miron is committed to building more than just buildings. We believe wholeheartedly in partnering with our clients to develop solutions that deliver business results. For many, that means increasing their bottom line, or enhancing their ability to recruit and retain the best and brightest. For others, it’s giving them a competitive edge. Our Experience-Based Design services offer our clients the ability to distinguish themselves in an increasingly competitive marketplace.

That is why we are committed to collaborating with owners and design partners to create unique, differentiating experiences that exceed client expectations. We know it is no longer enough to simply satisfy. At the end of the day, it’s all about helping our clients be successful. Experience-Based Design is just one way we’re helping clients deliver on their promises.

Simply stated: our commitment reaches beyond construction; our passion brings dreams to life!

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