Healthcare is rapidly changing at every level. While this evolution is obvious in the technologies used to treat patients, it also runs much deeper to affect the business model and even the facilities themselves. Over the last several years, U.S. legislation has created an environment in which healthcare organizations benefit from improved coordination. The result is the formation of accountable care organizations, which are networks of healthcare professionals and facilities that are designed to actively promote better patient care and more intelligent allocation of funds.
They key to a successful accountable care organziation is coordination. On the surface, this means different clinical providers working together to share information and eliminate redundant or unnecessary care. But it also affects new building projects and remodels, requiring efficient resource usage and intelligent management.
The trend toward ACO formation has a tremendous impact on facilities managers, as they work to manage physical healthcare resources. Because a single ACO may span several different buildings that are miles apart, intelligent planning is vital long before a new facility is operational. There are numerous considerations that must be made while taking into account the ACO's goals, as well as other facilities in the organization. This requires facility managers to be actively involved in every stage of the construction process, from understanding city zoning to evaluating construction sites. As part of this process, they must develop productive relationships with every professional who plays a part in constructing the building — from the architect, to the contractors, to the interior designers. Early involvement and intelligent decisions will save them time and money later on during the inspection process and can prolong the operational life of the facility.
The inspection process
It's difficult to overstate the inspection process as a vital part of adding a new facility to an ACO. Before it can begin operation, there are scores of codes and sub-codes that must be addressed during the design and construction process — and operationally on an annual basis thereafter, for the life of the facility. The code compliance requirements must have correlating documentation. Throughout the building and inspection process, facilities managers must keep in mind the specific function of the building. That will have an impact on the inspection process approach. Preparing for code compliance begins before ground is even broken, from the first stages in the design process; the facilities manager must be engaged during key steps along the way. Inspections take place at regular intervals, by different state and local authorities, requiring effective planning and coordination with the builders and inspectors.
External inspections
Facilities managers become a resource to many, in order to make the early inspection process manageable. They must become familiar with the different governing groups conducting inspections, particularly the accrediting bodies selected by their ACO. The state and local authorities, for example, will be involved in approving the initial plans for the facility and will not only take into account major details such as utilities, but also design details such as door hardware and wayfinding. The state and local authorities will also conduct a final inspection late in the construction process to ensure that construction has taken place in precise accordance to the plans.
In addition to state and local authorities, CMS recognizes three accrediting bodies which inspect acute care hospitals for compliance with the Medicare Conditions of Participation and Conditions for Coverage, one of which will be selected by the ACO. The accrediting bodies are:
- Del Norske Veritas, commonly referred to as DNV, is one healthcare accrediting body in the United States utilizing ISO 9001 standards in the inspection process and provides its standards for no cost, which can help facilities managers prepare for the inspection process. During the inspection process, DNV provides facilities with a simple score for each area surveyed that indicates satisfaction of requirements, or one of four gradations of noncompliance based on severity. Facilities are then either judged accredited or non-accredited. Following accreditation, maintenance inspections are performed on an annual basis.
- The Health Care Facilities Accreditation Program, is another healthcare accrediting body, which has maintained authority in the U.S. since the inception of CMS. HFAP requires a new facility to have at least 20 patient records before inspection can take place. Following the inspection, the facility will receive full accreditation, partial accreditation or non-accreditation. When deficiencies are cited, the facility has a specified period of time in which to rectify the issue, and it will be resurveyed. For continued compliance, surveys are conducted every three years.
- The Joint Commission is the third accrediting body, widely accepted and recognized by CMS for acute-care hospitals. It requires a minimum of ten patient records for accreditation eligibility. Accredited facilities are awarded the Gold Seal. Like HFAP, it conducts continued accreditation surveys for most facilities on a three-year cycle. The Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs in the United States.
Depending on the facility type, such as an ambulatory surgical center, behavioral health center, clinic or laboratory, other regulatory bodies are also recognized. Facilities managers are responsible for learning which requirements they will be responsible for, and they must coordinate with the organization throughout the building process in order to ensure that there are no delays in the inspection and accreditation. Any delay in the process means a delay in realizing the return on an enormous financial investment.
By taking an active role from the beginning, however, the facilities manager can implement efficiencies that will help meet codes and also reduce costs and complexity. Without input from the facilities manager, others involved in making decisions during the construction process may not have the complete picture. The architect, for example, may desire to implement a partial sprinkler system, in order to contribute to a budget-friendly construction. This may meet building code requirements adequately, but it will also impact the ability of the organization to meet other code requirements more easily. The facilities manager, however, may have an understanding that extending the sprinkler system throughout the entire building will reduce the steps needed to comply with other regulations and codes. In the end, a more extensive sprinkler system may actually realize a net reduction in operational costs because of other systems, such as fire and smoke alarm systems, that can be implemented to a more limited degree. This highlights the importance of the facilities manager choosing the most experienced professionals to work with, because it's impossible for a single individual to account for every factor that will contribute to the inspection and accreditation process.
The value of internal inspections
In addition to the external inspections that must take place before a facility is operational, the facilities manager should arrange for frequent internal inspections during the construction process. Again, using the best design and construction professionals available will help rein in costly mistakes, even if they are not the lowest-cost provider. Internal inspections will uncover issues that need correction before external inspections take place, allowing corrective action to be taken earlier than would otherwise be possible.
Frequent internal inspections, and keeping external inspections in mind with every decision facilities managers make, reflect the mindset that a facility manager should have throughout the construction process. Compliance should be a continuous process rather than a periodic headache, and the biggest mistake a facilities manager can make is sitting on the sidelines during construction, assuming everything will work out and that other decision-makers will have the larger perspective in mind.
Meeting operational and sustainability needs
Constructing the building itself is only the first step in successfully adding a new facility to the ACO. There are several critical areas that need to be coordinated before operations can begin, and a good facilities manager will begin to consider these early on, in close coordination with the other professionals involved in the process.
Staffing
From the earliest stages of the design process, a good facilities manager is already considering staffing needs. In healthcare, the square footage of the building is often used to provide a rough estimate of how many staff will be required for successful operation, but this is only the beginning. With budgets too limited, and often being cut regularly in today's economy and healthcare environment, it's vital to find the optimal mix of skill sets that will provide patients with the best level of care while also adequately maintaining the building itself. Rarely will a facilities manager have the resources they would like to handle every aspect of the building maintenance, even in a large facility.
As part of an ACO network, however, facilities managers may be able to draw from a central pool of personnel with a variety of skills. And in many cases, a single facility may simply not be large enough to justify employing specialists to operate each type of equipment, from grounds maintenance to building infrastructure and equipment. The facilities manager will then be responsible for selecting the best talent, to perform the most vital tasks. If, for example, employment resources in a hospital aren't sufficient to bring in both an HVAC specialist and a full-time groundskeeper, they would most likely choose the HVAC specialist, whose skills could apply to a wide variety of functions in the facility related to patient care. Groundskeeping could then be handled on a part-time basis, perhaps by contracting with a service provider who handles other facilities in the ACO.
Purchased services and supplies
Healthcare facilities require an enormous amount of coordination to maintain services and supplies. At the heart of their operations is the computerized maintenance management software that helps them manage systems, processes and costs. A new facility will also benefit from adopting the same building automation system as the other facilities in the ACO. This potential gives them cost savings if they can simply add a new implementation to an existing contract. Additionally, they will be able to reduce the learning curve of staff in operating the system if other employees in the healthcare system are able to transfer to the new facility or provide training for new staff members.
Facilities managers are also responsible for the day-to-day supply needs of the building, from the nuts and bolts needed for general maintenance to filters and lubrication for maintaining the air conditioning system. Wherever it is appropriate, it will be beneficial for the facility to use the same suppliers as others within the network. If the current providers deliver quality products, coordination will save the facilities manager time in one area of management, allowing that attention to be focused on other critical decisions that must be made. This approach also delivers the benefit of keeping supply costs lower through volume discounts. In addition, it can simplify the process of negotiating continued supply contracts.
Utilities
The question of utilities may be complex, depending on where the new facility is located relative to other buildings in the ACO network and the location of the facility on the utility provider infrastructure. In this case, rather than standardizing with other ACO facilities, it is best to focus on efficiency and reliability from the design stage onward. This is a crucial point that will have a fiscal effect throughout the operational life of the facility. The designers will be concerned about the budget and may have relationships with certain vendors. Without the intervention of the facilities manager, they may desire to use discounted equipment such as outdated components, thinking it will help the project to come in under budget.
It’s vital, however, that the FM take a long-term view with utilities. It's important to use the most cutting-edge, energy-efficient components available, even at the higher cost of earlier adoption. One example would be the lighting in the building, which is one very significant source of operational costs. LED lighting, for instance, may be more expensive than fluorescent fixtures at the time of construction, but they use less electricity, have longer lives and are cheaper to dispose of. While the up-front cost may be greater to install LED-compatible fixtures, using fluorescent fixtures would likely result in higher lighting costs. Additionally, future upgrades to adopt LED lighting would be more expensive than installing the LED fixtures up front. Future-proofing the utilities is one of the most significant areas in which the facilities manager should play an active part in the construction process. Also of interest is the facilities manager's knowledge of the local utility market and incentives for use of efficient equipment.
Reliability and sustainability
An experienced facilities manager will already have a sense of the equipment that will be the most reliable in the long term, requiring the least maintenance. Hospitals are required to install generators, for example, to handle power outages, in addition to redundant electrical grid connections. The highest quality equipment should be used throughout the hospital, not only because lives are at stake, but also because the cost of replacement makes the original investment worthwhile. Hospital facilities normally keep a listing or matrix of the equipment and supply standards for their organization. This list provides the manufacturer and a detailed history of those components for life cycle purposes.
Conclusion
The role of the facilities manager is difficult to overstate in every stage of adding a facility to an ACO. They must be intimately involved at every stage of the design and construction process, developing productive relationships that will ensure a healthy addition to the physical infrastructure of the healthcare organization.
The facility manager's impact on the facility extends beyond the beginning of operations, however. One aspect of healthcare facilities management that is often underestimated by the healthcare organization's leadership is the need for continuous capital investment into the building throughout the life of the facility. It can be a challenge to convince decision-makers to take the long view and put money into operations before repairs are needed. But as with regular car maintenance, up-front investment minimizes later expenses. The other "uncertainty cloud" is the Patient Protection Affordable Care Act and the yet-to-be written policies and reimbursement models. This affects revenue, capital availability, investment strategies and project workload.
Studies have shown, two to four percent of a facility's net asset value should be reinvested into the infrastructure, annually, in facility capital renewal. This will be a challenge for hospital leadership and facilities managers, with continued pressure in the healthcare industry to cut costs wherever possible. If, however, this reinvestment does not take place, the facility will have a shorter operational life, quickly reaching a point at which the ACO must either make a major investment into repairs or may be forced to discontinue or repurpose the use of the building.
By playing an active role every step of the way, an effective facilities manager can influence the health of patients — and the healthcare organization itself, strengthening the ACO and adding value to the community.
Rob Scheffer has been a dedicated leader in facility management for over 25 years in the healthcare industry. His professional affiliations include the American College of Healthcare Executives, American Organization of Nurse Executives, Association for Facilities Engineering, Association of Energy Engineers, and American Hospital Association’s American Society of Healthcare Engineering. For more information, contact him at rob.scheffer@abm.com. ABM’s Merrill Kaney, Regional Director of Operations – POM, ABM Healthcare Support Services, contributed to this article.