ACE Blog

Vincent "Vinny" Boles
Major General, U.S. Army(Ret.)


On July 4th, America celebrates its birthday. That day when, in 1776, the Continental Congress approved the Declaration of Independence drafted by its “Committee of Five”: Thomas Jefferson, Benjamin Franklin, John Adams, Robert Livingston and Roger Sherman. (History tell us that Jefferson served as the primary drafter, with the other four serving as editors and contributors.)

One though always returns to this “Soldier for Life” (43 years thus far) on the 4th of July.

“For these freedoms to be sustained, they must be secured.”

The Continental Army was born in 1775, initially to eject the British military presence from Boston. (Which it did in March 1776.) This success enabled the colonies to visualize a successful revolution and possess the confidence to draft the Declaration of Independence.

In a war that lasted over 8 years (1775-1783), the Colonial Army won only 3 victories on the battlefield, Trenton, Saratoga, and Yorktown, but their fortitude and stamina secured independence for those 13 colonies.

And now 243 years after its establishment, America’s Army, YOUR ARMY, continues its mission to secure our freedoms. The security of these freedoms we celebrate on the 4th of July is not guaranteed and future stability is not pre-ordained. It must be defended.

It’s worth taking a moment amidst the fireworks, barbecues, onslaught of red white and blue color schemes and patriotic music to consider this and dedicate ourselves, the beneficiaries of service, to be the types of citizens worthy of their service.

Have a Happy Birthday America! And always, “Army Strong”.

Gloria Cascarino
Senior Associate and Director of Medical Equipment Planning
Francis Cauffman
Good News and Ah-Ha Moments
Capital Equipment Planning Challenges for Outpatient Care
Outpatient Care Centers offer “one-stop-shop” convenience for patients, often including Imaging and other diagnostics, Ambulatory Surgery and Procedures, Urgent Care, Lab Services, Rehab and Physicians’ Practices.  This variety of services presents unique challenges for Capital Equipment Planning – with key considerations of throughput, budget and space (and storage!) limitations.  In many outpatient settings, there’s often a wide variety of clinical conditions presenting –
requiring a wide selection of necessary equipment.   Freestanding EDs see adult and pediatric patients, and even women in labor and unstable cardiac patients.  Ambulatory Surgery Centers offer different types of surgeries – from joints to biopsies to wisdom teeth!  And, what about those Diagnostic departments?  Often, they represent the biggest portion of the project’s equipment areas and budget.  With a limited amount of available space, and maybe a short design window, the project team will look to you for your special expertise, so you’ll need to come up with a fair amount of creativity and future-thinking.  
Now’s the time to put on your “Consultant” hat, and reach into your bag of tricks.  It’s your turn to be a hero!  (This is the part where you get some “Good News and Ah-Ha Moments”)
Here are some suggestions:
1.Repeat after me: “Increase the volume, not the space.”  Chances are good that storage spaces are at a premium – with patient care and revenue-producing spaces being the focus of the design.  You may find yourself caught in the middle – between the clinicians and their storage needs and the design professionals who have been charged with fitting all of the required Program requirements into a specific envelope.  One of the best solutions is to limit (or eliminate!) the amount of “air” that will be stored.  Yes, that’s right - air is not your friend.  Efficient supply and minor-equipment storage is an absolute must.  You won’t be able to increase the storage space, so you will have to find a way to increase the volume of things you can accommodate.  Fortunately, there are clever options for high-density storage – with tracks on the top or the bottom.  Also, you will want to take a close look at the actual items to be stored.  Armed with that knowledge, you can recommend a shelving arrangement that specifically accommodates them – like panel systems, either wall-mounted or free-standing.
2.You can offer creative surgical-table solutions, some of which will alleviate the requirement to designate an OR for a particular type of surgery.  Flexible tables, with a wide assortment of accessories, can accommodate many different types of surgeries – helping you to support a “Universal OR” concept.  (Be the hero!)
3.There are HUGE advances in technology for Diagnostic Imaging – equipment with a much smaller footprint, and even equipment that challenges the need for a full-size Control Room.  If you haven’t been keeping up with these new machines, now’s the time to reach out to your sales reps for support.  They’ll be happy to share their “good news” with you, and provide the specs that you need for your project team.
If you’d like to hear more about this topic, and see pictures of some of these solutions, join us in ‘Augusta EF’, at 1:00 PM on Monday (2/19), for The Changing Nature of Equipment Planning.  I look forward to seeing you there!
Philips Blue Jay Consulting
What Happens the Day After the Open House and the Honeymoon is Over!
By John Davanzo, MBA, BSN, RN, EMT-P, CEN, NEA-BC, FACHE
Consultant, Philips Blue Jay Consulting
It’s a classic conundrum, a new emergency department has been built as part of a renovation or new hospital and shortly after it opens, there are requests for change from clinicians and staff. Is this just a case of designers, architects, and facility professionals are from Mars and clinicians are from Venus or is there more to it than that?
One of the foundational things that we often acknowledge but then, it seems, lay aside is the rapid pace of change. Change can take the form of new technology (we want a CT in the ED to support the new stroke program), new government or regulatory body rules (now every room needs to have foam or a sink by the door) or it could be the most recent disaster headline or communicable disease - from Anthrax in 2001, H1N1/Swine Flu in 2009, or Zika in 2016, and the list will go on.
All of these can quickly create the need for change in how patient flow occurs and how space or rooms are utilized or function. This is before we even touch on process improvement, clinician preference, or patient demands.
Many things can impact what clinicians perceive as “poor space”. It may not be welcoming from the beginning, clinicians may not have been involved early enough in the design process, there may have been design constrictions due to budget, geography, or client demand, or the space may just be dated and unable to support the current demand. Often, the two biggest items missing from a clinician standpoint are convenience and flexibility.
We know new technology, regulation, disasters, patient surge, and communicable disease are likely to happen, so why are we not building them into the plan?
There was a time when disaster management included having a plan for any conceivable problem, which became unmanageable. The concept has evolved to keep pace and remain relevant - today, we use what is called an “all hazards” approach. A similar approach is needed for ED design to integrate a level of flexibility to meet the changing needs of patients, technology, and emergency care situations.  
We know things are going to happen and demands will change so we must design a space that supports more efficient flow and one that can scale to support the situation as needed. I have found that applying some of the same basic concepts of the all hazards approach including flexibility and modular capabilities to patient rooms and space in healthcare facilities avoids some of the constant rework or remodel. And, it is best to gain input and agreement when possible from the clinicians and staff to ensure issues are resolved and priority needs are addressed.
Join me at the 2018 ACE Summit for the breakout session Innovative Construction Contracting, where we will look at this very issue.
Walter Jones,
Vice President of Campus Transformation
The MetroHealth System
Building A New System of Care in Cleveland
We are re-imagining everything about MetroHealth, including its physical environment. We are focusing on wellness, prevention and chronic care management to reduce the need for inpatient care as we know it.
The campus transformation to support this effort will require nearly a $1 billion commitment from the system. It will be spent on nearly 2 million square feet of new and upgraded facilities to replace the aged infrastructure and facilities on our main campus.
I think every construction project in health care is unique, but MetroHealth may be even more so. Our main campus grew organically; the oldest parts are now more than 100 years old. These facilities are all interconnected, so simple things such as water pipes and wiring don’t match up. You have to work well with facilities management - good communication keeps the hospital going while we are moving ahead. Ideally, the facility is maintained in a constant state of readiness for any level of operation it may be called upon to do.
Our new work is the result of a thoughtful strategic plan. Our new campus in Cleveland will have fewer, but more flexible beds that will be designed to serve the diverse needs of patients. Our network of health centers are simultaneously expanding out into the communities we serve so patients can access care closer to their homes and workplaces. Right now, there is a MetroHealth site within a 10-minute drive of anyone in Cuyahoga County.
We have completed two steps of our campus transformation so far. In 2015, we demolished a vacant and unused 1922 bed tower that housed Northcoast Behavioral Healthcare. In June 2016, construction was completed on a new, $82 million critical care pavilion built over our existing Level 1 Adult Trauma Center and surgical suites. We built 85 state-of-the-art ICU rooms and also a Special Disease Care Unit to serve as the regional Ebola treatment center, the only one in the state of Ohio.
I have done a large, replacement hospital once before, having led a successful, but exhausting, rebuild of Parkland Health & Hospital System in Dallas, which is also a public entity. This work is about the future of health care. If you can’t get excited about that, you just need to try another kind of job.
John Brownrigg
Former Vice President, Real Estate and Facilities,
Mercy Health
The Soul of A Construction Project
The world I work in is complex, decentralized, busy and never dull. I manage projects in two states (Ohio and Kentucky), for 22 acute care hospitals, hundreds of post-acute care facilities and other access points to our healthcare system. My team has more than 50 projects under way, with a spend north of $250 million. We work in eight different markets, so each time we do a project, we are dealing with many different user groups. We would love to standardize and centralize everything we do, but reality interferes. We adapt to each market.
I believe that every project develops a soul somewhere in its lifecycle. This is a result of the collaboration of the design team, the vendors, the executive leadership, the people from our office, and numerous other stakeholders. Contracting is a part of this soul; our biggest initiative in this regard is to make sure that all the players on the team – the architects, designers, the construction contractors – all have the same incentive as we do to get the project done right, done on time and on budget – or better. You can’t get everyone on the same page after the fact. It has to come right at the beginning, as part of the pact we make to collaborate, not just make money.
Beyond contracting, the other part of the soul is to make sure everyone understands the reason this new facility or project is coming into being. We want all the players on the team to have top of mind that enhancing the patient and care-giver experience is why we are here. Bricks and mortar are just bricks and mortar if a project isn’t designed to add value to healthcare delivery in the local market.
In practical terms, we often go into a process without a firm idea of scope, so we need to be flexible with the form of contract we use.  The contract needs to provide the proper incentives without leaving too much money in other parties’ pockets. A guaranteed maximum price works if we have a very fixed budget and have a good handle on the scope. A cost-plus contract is used when we are still working through the scope and anticipate additional changes during construction.  Many other hybrid forms of contract exist and are utilized when appropriate.
There are many kinds of incentives, of course, and probably the biggest one of all is about personal relationships. This goes back to my notion of the soul. You work with a contractor on enough projects and you get efficiencies from them knowing what you are looking for before you know. And there’s the stick, too; if the vendor doesn’t deliver on this project, they know they are not going to get the next one. But we prefer to getting all the players aligned through incentives and working together to lower costs and improve quality.  Epic projects are achieved when everyone is on the same page, we are all working for a common goal, and we all are fairly compensated for our efforts.
Finally, once we deliver a project, it is just the start of something, not the end. We watch a new building or facility for what’s working and what’s not. We want to deliver more on the next project. Often it is the mistakes we learn the most from, but the wins also inform future design and build processes. A new building has a soul, and we want to carry forth the best of that to our future work. 
Gloria A. Cascarino
Senior Associate Director of Medical Equipment Planning at Francis Cauffman
Big Savings from Energy-Efficient Medical Equipment?​
Hospitals are major energy consumers in their communities, spending over $8 billion on energy each year.  Medical equipment accounts for 12 to 18% of their total energy use.  As hospitals add more technology, energy costs are sure to rise.  Well, here’s the good news: Newer-generation medical equipment can help hospitals to reduce their overall energy consumption while actually increasing their use of energy-intensive medical equipment.  Major manufacturers offer energy-efficient equipment that yields significant savings, when compared to previous models.
So, what’s new, how is it better, and how can you help your organization achieve those savings?
What’s new and how is it better?
Here are a few categories of new equipment that offer those significant savings:
Instrument Processing
As we know, instrument washers use significant amounts of water and electricity. Newer models can use up to 70% less water, with faster cycle times for increased throughput and energy savings. Some of them even offer a greater capacity in a smaller footprint!
Imaging Equipment
New CT Scanners, MRI Magnets, and even Ultrasound Machines reduce energy use by 15 to 30%, and many of them offer quicker scan times for better throughput and patient satisfaction.  Majpr diagnostic equipment also has stand-by modes, using less energy at times of lower usage – like evenings and weekends.
Clinical Lab Equipment – Hoods and Ultra-Low Freezers
Fume hoods can represent up to 60% of lab utility costs. Today’s hoods have features that save energy and improve staff safety at the same time.  Some older hoods can be retrofitted with some of the new features!
Ultra-low Freezers use between 10 and 20 times the energy of an average household refrigerator/freezer!  New models can reduce energy usage by 66%, paying for themselves within 3 years.
In addition to these categories, ice machines, refrigerators and even computers are offered with Energy Star ratings – with lower operating costs over their predecessors.
How can you help your organization achieve energy savings from medical equipment?
Here are some of the ways that you can implement equipment energy-savings initiatives:
1.Assess the age and energy performance of your existing equipment for prudent reuse decisions.  (We know that your equipment may exceed its ‘average useful life’.)  How many newer generations have become available, and what savings can new models offer?  Hint: Don’t just consider major equipment.  Even minor equipment that runs continuously, like infusion pumps and monitors, can be costing more to operate.
2.Enlist the help of your sales representatives, who can calculate the ROI for new equipment.  Even your GPO may have programs and data for this effort.
3.Add energy efficiency criteria to your requests for quotes – so that you can consider them in equipment selection decisions.
4.Finally, don’t forget to benchmark energy savings after new equipment is in use, so that you can quantify the capital that can be reinvested in new equipment.  Then celebrate!
At a time when hospitals are competing for market share and dealing with reduced reimbursements, being a good community partner and identifying hidden savings are critical for their success.  It’s great to know that medical equipment can play an important role in a healthcare organization’s overall energy management plan. 
Sean Poellnitz, BS, CHRM
Director, Contracting & Resource Utilization, Supply Chain Management, 
Creating Smarter Capital Programs
Historically, much of the strategic contracting focus has been around clinical products in healthcare. As our healthcare world has progressed under ACA healthcare supply chains, organizations are becoming more robust in their ability to drive strategic program in areas like purchase services and Capital Programs, which have now shifted to the forefront of everyone’s minds. As we dig deeper into creating smarter capital programs, we do start to mirror some of the same challenges we weighed in the clinical product service lines mixed in with a more commercial approach when looking at the “true cost” of capital.
What to buy?
As we start thinking about our capital needs and standardization, we start asking ourselves questions around making sure we have the “right technology fit” when looking at our technology options, including making those decisions based on the clinical evidence. I think we are over the point of just benchmarking our capital price and walking away with our work being done, but Supply Chain organizations are now peeling back the onion to really drive value in ensuring that we are giving the stakeholders the “right technology fit”. This concept plays into two areas: 1) Making sure that we aren’t buying the Lexus when we need the Honda and 2) Being forecasters, if not, investigators ensuring that our requesting departments don’t go too low-end on the front end nevertheless, in the near future needing substantial upgrades because they don’t have a unit that can support the traffic of their operations, the health needs of their population or the niche needs of the clinical program.
How much does it cost?
Earlier I hinted at capital benchmarking which step one is still the bread and butter in reviewing the competitiveness of our capital quotes, but the smarter Supply Chain organizations are reviewing the total cost of ownership (TCO).  From reviewing the national average maintenance cost for equipment or leveraging our internal BioMed partners to understanding our own internal maintenance cost for the life of the desired equipment per our environment. Notwithstanding the above being proactive with our IT stakeholders we are also becoming more sensitive and wise to understanding the costs to support the new capital in our current infrastructure.  Furthermore, by having conversation in advance of acquisition with IT and Health Informatics we have avoided costly missteps ensuring that we aren’t overlooking that extra server or maybe having the right version of windows pre-installed on the unit.  Along the same lines of thought we are starting to look at how we can drive better warranties, the cost of software upgrades and potentially if there are qualified refurbished units in the aftermarkets to meet our needs.
Do we have a standard?
As I talk to my peers across the country, we agree that standardization is the key to us properly wrapping our hands around fleet management and giving us the seeds to strategic partner with our capital suppliers. A new vision that many leaders like myself are embracing is that capital is not just a piece of equipment but really it represents solution to a clinical need that can be formed into a program. It’s a culture shift but many times it takes an extra step to not get caught in the current fire drills but manage our equipment needs as fleet instead of multiple independent acquisitions for our health system. The science of a clinical standard is that it helps drive the following: 1) The ability to be open to long-term agreement that drives a substantial clinical value including being able to drive clinical programs 2) Leverage a competitive situation with suppliers to leverage fixed price over the life of the agreement including controlling cost of the disposals 3) The relationship yields to deeper sourcing innovation and yields a valuable supplier partner that can aid us in maturing clinical environments especially in times when we need supplier partners as consultants in aiding us to drive solutions to new challenges.
Lastly, if all works right upcoming needs that rest in the areas covered by the standard can be addressed quickly allowing us to focus more time on critical areas of the business.  End game clinical equipment standards help us “to get things done” and no one is fighting having fewer initiatives off our plate while providing our clinical stakeholders the “right solution”.
Final Thoughts
Now of course there is never a one size fits all solution but the hope is that as we collaborate we will all help each other drive better ideas from our experiences. Above all we can’t forgot that we must collaborate with our supplier community and partner with them for the best solutions while always expecting the best intentions for all parties involved. Truly, as we share ideas across IDNs and building better capital programs I look forward to seeing you all at ACE Summit to hear about your successes, lessons learned and opportunists for the future.
Sheila F. Cahnman, AIA, FACHA, LEED AP
JumpGarden Consulting, LLC
Federal Legislation and Healthcare Design
As if designing and equipping healthcare facilities wasn’t complicated enough, our clients are subject to an ever changing array of laws and regulations, in addition to changes in technology and medical practice. Without constant awareness of current changes and trends, the healthcare planner can easily be left behind!
For instance, let’s look at Federal legislation passed late last year and how it affects healthcare design:
Last November, the Bipartisan Budget Act of 2015 became law. Section 603 of the Act has a major impact on reimbursement for hospital outpatient services located away from their hospital campus. The Act changes Medicare reimbursement for outpatient services furnished in off-campus provider-based departments (PBDs) to lower rates based on the Medicare Physician Fee Schedule or the Ambulatory Surgery Center payment system, effective January 1, 2017. Legislators were not happy that hospitals would acquire private physician practices, and then transform them into hospital departments in order to receive higher Medicare reimbursement.
The exceptions include on-campus ambulatory care facilities, Off-Campus PBDs that will be "grandfathered" if operational in November 2015, freestanding Emergency Departments and entities that provide different services from the hospital. The Act will consider a facility as a PBD on-campus if within 250 yards of the hospital’s main buildings (even if on a different hospital owned property) or at a satellite hospital on a remote site.
Hospital advocacy groups believe increased reimbursement is appropriate since if a space is considered provider-based, it must meet State and Federal requirements for life safety codes and integrate with hospital clinical and financial systems. Other groups have called for the same reimbursement for a service or "site neutrality", regardless of setting.
The last few years have seen a proliferation of large off-campus ambulatory centers or “hospitals without inpatient beds”. Many of these facilities, especially in growth areas, are located to capture market share, while increasing revenue. Will hospitals continue to develop these facilities, especially with Diagnostic & Treatment platforms, under the new reimbursement rules or will services migrate back to hospital campuses?
The new law is also unclear on the following points:
  • If these existing PBD facilities are “grandfathered” will they be allowed to expand footprint or services and retain higher payments?
  • Can an already sanctioned Off-Campus PBD move to a new location and retain payments?
  • If a project was already in development in November 2015 and has not yet opened, the project may be based financially on the former higher reimbursements. Will the law be modified so these projects are not penalized?
The changing reimbursement climate, as well as the advent of telemedicine may indeed reduce the amount or change the complexity of outpatient facilities in coming years. As with all healthcare trends – you never know what to expect!