optimizing healthcare assessing waste in project definition, design and delivery and implementing...

Optimizing HealthcareOptimizing HealthcareAssessing waste in project definition, design and delivery and implementing methods for removing it

May, 2010

5.2010

© Copyright 2010, David F. Chambers. All rights reserved worldwide.

HOPEHOPE

“never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.”

Margaret Mead

5.2010


Current trendsCurrent trendsDemand for care capacity is causing a

hospital building boom throughout the US

The trend erroneously presupposes that there will be enough care professionals to meet the needs of patients in these facilities

As a percentage of GDP, US is already over 16% - slated to increase to 19.5% by 2017 – costs projected to continue to rise at a rate of 6.7% per year

Cost versus access is at a breaking point

Each and every one of us is paying for this healthcare model!

5.2010


The Sutter Health Capital The Sutter Health Capital ProgramProgram We are faced with the conundrums of current trends

like all providers We are also faced with SB1953 – the California

Seismic Safety Act Sutter Health is a 28 hospital/multiple

foundation/clinic system with a $6.5B - ten year special capital program

Approximately 6 years ago, we acknowledged that to move forward successfully, we must not do what we have done (conventional project planning and delivery) if we expected anything different

We became early adopters of “lean project delivery” In 2007, we also rethought project planning and

design – this was our “Prototype Hospital Initiative”

5.2010


Costs of healthcare annually Costs of healthcare annually distributeddistributed

Operationalizing Care: 72%

Housing Care: 8%

An example: hospitals in the State of California Distribution of direct expenses by natural classification

Source data: Office of Statewide Health Planning and Development. Data extracted from hospital annual financial data file for report periods ended January 1, 2006 to December 31, 2006. The data were extracted on September 18, 2007.

5.2010


Architecture: an undiscovered Architecture: an undiscovered value propositionvalue proposition Architecture is about the design of spaces in which

particular ways of being, disciplines, activities, and human enterprise are invited, made possible and made visible

◦ “... optimized work flows provide for dramatically improved patient safety and delivery of high quality care; they produce great outcomes and promise significant cost reductions in delivering that care.”

source: Efficient Healthcare Overcoming Broken Paradigms (David F. Chambers)

Architecture has the capacity to make an enormous contribution in virtually every kind of human enterprise

◦ “The important point about fixed-feature space is that it is the mold into which a great deal of behavior is cast.”

source: The Hidden Dimension IX. The Anthropology of Space: An Organizing Model, Fixed-Feature Space (Edward T. Hall)

Architecture can help to build virtual bridges from pasts that are no longer satisfying to futures we choose5.2010


Why architecture is not Why architecture is not perceived this wayperceived this wayThis type of conversation represents

greater risk◦ Solutions are not based on traditional design

formulas and legacy code interpretations◦ Prevailing wisdom is to take comfort in

numbers e.g. decisions supported by EBD◦ Language of operations is not directly linked

to language of space – requires greater learning

◦ Strongest inclination is to optimize immediate firm benefit (profit) rather than total solution (this is a systemic problem throughout design and construction industry)

5.2010


INSANITYINSANITY

… “doing the same thing over and over again and expecting different results!”

Albert Einstein

5.2010


Project definition, design & Project definition, design & delivery for effective delivery for effective healthcarehealthcareif we can imagine remarkable

improvements within the acute care environment, do we have the will to achieve them?

what are our assessments regarding waste?◦patient movement

◦staff movement

◦ inventory

◦procurement processes

◦project delivery5.2010


Project definition: programming to Project definition: programming to remove waste in care deliveryremove waste in care delivery

Standardized spatial allocation for single station care concept reduces handoffs, queues and cycle times thus improving care efficiencies.

Capacity configured as standard single bed environments designed to accommodate a broad bandwidth of care processes operated by multidisciplinary care teams – we call this a “Universal Care Unit” (not an inpatient unit), which acts as a throughput hub for D&T services. Processes to be housed include:◦ Observation◦ Emergency Exam and Treatment◦ Preadmission Testing (Lab, EKG, PFT, Consults…)◦ Invasive Services Preparation◦ Step-down Post Operative Care◦ Visiting Clinic Programs

Rooms are 120 to 140 NSF and configured similar to standard exam rooms

High degree of standardization allows for maximum implementation of Impact II and III solutions. 5.2010


The benefits of getting it The benefits of getting it rightright

5.2010


What’s next?What’s next?Decoupling technology from architecture

Buildings become obsolete too quickly Metabolism of technologies is much faster than

buildings Integration of technologies into architecture

significantly increases cost◦ Proposal is to develop smart care platform –

technologies in equipment (bed) in lieu of spaceExploring the manufacturability of

healthcare environments Buildings are unique inventions that consume

substantial resources, take long to complete, and are costly to build

◦ Proposal is to develop standardized kit of parts allowing for high aesthetic variability, simplified and rapid assembly, safe standardized care environments

5.2010


5.2010


Project delivery – leaving no stone unturnedWaste in the project delivery process

begins with poor problem seeking, but it certainly doesn’t stop there.

Handoffs, queues, and rework are rampant in project delivery just as they are in healthcare delivery

How might we break from the wasteful traditions of this model?

The Integrated Project Delivery The Integrated Project Delivery Team: roles, responsibilities, Team: roles, responsibilities, relationshipsrelationships

5.2010


Target Value Design: Target Value Design: realizing the value of realizing the value of collaborationcollaboration

5.2010


Construction Estimate Total -Comparison to Market Trends

Information courtesy of HerreroBoldt

Design and project Design and project delivery – a tale of two delivery – a tale of two

projectsprojects

Project I Project II

◦ New Women’s and Children’s tower to house 257 new beds in 398K SF – bridges to exist hosp. for D&T, ED and support, with 202K SF renovations to exist hosp. and 63K SF POB/CUP

◦ Original program developed by outside architectural expertise of 252K SF required substantial correction to 398K SF

◦ initial budget assumptions increased from $254M to $385M in 2003

◦ 130 bed replacement Hospital for East Bay to house full spectrum of acute care, D&T and ED services

◦ Facility housed in 214K SF◦ Preliminary program developed

by FPD within 350 SF of final design

◦ Initial budget assumptions validated at $320M

5.2010


Project deliveryProject delivery


• Project team selected in 2001 to deliver $254M Project

• A/E and CM selection separate processes

• Team selected by affiliate - FPD acted as advisor

• Contract delivery model: CMGC at Risk

• Classic split agreements Owner-Architect, Owner-CMGC

• Main subcontractors selected well into design phase services to “assist” with design to budget

• Affiliate (generally inexperienced in project delivery) holds all contracts - is final decision maker

• FPD in advisory role

• Self-assembled team selected to deliver $320M project

• Single (integrated team) selection process

• Team selected by FPD• Contract delivery model:

Integrated Project Delivery• IFOA Multi-party Agreement –

One contract binds all parties• Main subcontractors selected

prior to design start

• Corporation holds IFOA contract

• FPD is corporate representative and therefore responsible decision maker on project for scope and budget issues

5.2010


Permitting processPermitting process


• Traditional incremental plan review

• Permitting authority reacts to submitted drawings

• Large design packages submitted for approval

• Design drawings lacked constructability detail resulting in numerous change orders – restarts in permitting process

• Phased incremental plan review

• IPDT collaborates with permitting authority during design process

• Small design packages submitted for approval

• Design drawings developed in BIM based on explicit constructability detail

5.2010


Escalation & scheduleEscalation & schedule


• Project initiated in 2000• Extended pre-design process

due to early gaps in program assumptions caused design delay to 2004

• Escalation from 2003 to 2007 is highest in history, equating to 86% over that duration

• Escalation often “hidden” in change order process – difficult to identify

• Project required 4 budget augmentations subsequent to Board Approval (from $254M to $725M)

• Project completion projected for June 2013

• Total project duration: 13 years

• Project initiated late 2007 with execution of Memorandum of Understanding

• Highly integrated design process (Target Value Design) responds explicitly to program and budget parameters requiring little to no rework of design

• Escalation held as identifiable/track-able contingency

• No budget augmentations required

• Project completion projected for January 2013

• Total project duration: 5 years

5.2010


Current project statusCurrent project status


• 13 years project duration• Steel erection of W&C tower

not started• To date: 640 RFIs and 159

change orders (W&C Tower only)

• 4 budget augmentations• 3 years schedule slippage

• 5 years project duration

• Steel erection topped off 4/27/2010

• To date: 51 RFIs and 12 change orders

• Project on original budget

• 0 days schedule slippage

5.2010


Key lessonsKey lessonsWe are all vested in the success of the

healthcare industry!Collaborative models can drive out

significant waste (handoffs, queues, restarts, rework)◦ This is true for healthcare delivery◦ It is also true for project delivery

Highest collaboration requires a collaborative “owner”

New collaborative models require a different approach to optimization (of the whole – not the pieces) and a different mindset

Maintaining the status quo is NOT a viable option for healthcare or for the design and construction industry

5.2010


optimizing healthcare assessing waste in project definition, design and delivery and implementing...

Documents

broken paradigms david

care capacity

housing care

care professionals

delivery of high quality

conventional project

project definition

costs of healthcare