Boston Hospital Battles Changing Standards to Contain Costs and Enhance Efficiency

by HCE Exchange on June 17, 2014

Bob-Biggio-thumbRobert Biggio, Vice President of Facilities and Support Services

Many exciting changes are happening in the way care is delivered at the bedside, but with efforts to contain costs and increase efficiency, facilities and support services are being transformed as well.

Boston Medical Center (BMC) in Massachusetts is in the early stages of implementing a $270-million clinical campus redesign to support patient care delivery and reduce overhead costs for the organization.

BMC was formed in 1996 by the merger of two full-service hospital campuses located only two blocks apart. This created a “split” campus rife with inefficiencies.

A major part of the real-estate strategy is to redesign the campuses to reduce overlap and upgrade facilities. The to-do list includes expanding the emergency department, creating a cohesive women’s and children’s facility, consolidating intensive-care units with appropriate adjacencies, designing a state-of-the-art radiology department adjacent to the ED, and creating a single interventional procedure site, among other upgrades.

Robert Biggio, vice president of facilities and support services, said he expects the project to save approximately $25 million annually in overhead costs.

Using Integrated Project Delivery for collaboration

For the primary inpatient facility project, estimated at $130 to $140 million, BMC is using an Integrated Project Delivery (IPD) approach. This will be the first full healthcare-related IPD project done in Massachusetts.

According to Biggio, IPD brings together the designers, owner, and contractor much earlier in the project, and they sign one three-party contract. The charges for each consultant are stripped down to actual cost, and all profit that is traditionally added to contracts is instead placed into a central pool shared on a percentage basis by each of the parties who have put their profit at risk.

That pool is at risk throughout the project, motivating everyone to remain aligned to the common goals. All consultants are relocated onsite for the length of the contract to encourage collaboration among the teams.

Biggio said BMC has a dedicated 9,000 square-foot colocation space for up to 90 staff consultants and owner’s representatives to meet, work, and interact. BIM 3D technology makes this approach possible, allowing everyone to work on one 3D model of the entire project rather than individual drawings.

“So far, I am sold on this process,” Biggio said. “The level of collaboration and integration this process encourages is impressive. We are leaning toward this being our standard going forward on large-scale projects.”

Incorporating evidence-based design and sustainability

Biggio said BMC tries to take a logical approach to building projects that accounts for future needs and environmentally friendly elements, but it always keeps in mind that the space has to be usable for those providing care.

Building in flexibility is one area where Biggio said the organization tries not to overestimate to the point where it incurs additional cost in the present.

“People have tried to guess what’s coming, so they install things thinking they will be needed,” he said. “A better approach is to build in flexibility without incurring the cost today of adding extra elements.”

He said most projects at BMC build flexibility into the size of spaces and access to spaces for getting equipment in and out. He also said ceilings in the operating rooms are another area to add flexibility, as more equipment is being hung from above rather than planted on the floor.

As far as sustainability, Biggio said he takes a more “meat-and-potatoes” approach to LEED.

“If you get too focused on LEED points, you may lose sight of the fact that some technologies being installed are difficult to maintain,” he said. “Many facilities are built with the intention of how they should be used rather than how they are actually used. We focus on the way systems will be maintained and operated and make sure that what we incorporate into the buildings at the outset are aligned with those efforts, then provide training.”

Some energy-efficient options cited in LEED are not utilized, rendering them no longer efficient, a lesson Biggio learned the hard way.

BMC recently completed a LEED Silver ambulatory care facility. Once he dug into the maintenance and operating strategies, the building was no longer as efficient as hoped. BMC has since gone back to modify the control sequences and programming and is now able to realize the full potential of the energy-efficient technologies going forward.

Challenges in a changing environment

Cost containment and regulations are a challenge in all areas of healthcare, and facilities are no exception. As the market turns around, buildings costs are on the rise. With most organizations modifying existing facilities, the main push is to support efficiency across the spectrum in the way care is delivered.

Facilities are an overhead cost, so the more efficiency driven into the system, the more resources are available to care for patients. In Boston, state regulatory design and construction guidelines present a challenge to achieving maximum efficiency.

The Facility Guidelines Institute publishes guidelines for healthcare construction, but Massachusetts has adopted those guidelines as requirements, requirements that don’t always translate into what’s most effective for healthcare.

One example Biggio gave is in the women’s and children’s department. The average daily census for the nursery is two babies. However, the state requires the hospital have one bassinet in the nursery for every maternity room plus one, a total of 31 bassinets for BMC.

“You have the industry telling you what’s best for practice, but the requirements for how you build space haven’t caught up,” he said. “Being required to follow these standards in a stringent manner creates obstacles in our attempts to be fluid the way reform is asking for.”

All in all, Biggio said the main focus of any facilities project should always be on the patients and those providing care.

“Buildings are tools we provide clinicians to meet certain objectives or goals to provide exceptional care to our patients,” he said. “We need to make sure we fully understand what those goals and objectives are and to design facilities that align with and support them.”

-by Patricia Chaney

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