INTEGRAL PROCESS DESIGN. Synthesizing Building and Business Design of Health Care Buildings

Professorial Dissertation , 2010 , 170 Pages

Nursing Science - Nursing Management

INTEGRAL PROCESS DESIGN [IPD]: ABSTRACT
Improved Planning and Operations for Complex Buildings

Starting Point:
Health care systems throughout the world face financial collapse. Costs must be reduced. This study shows a significant cost reduction potential of hospital running costs which account for ca.25-30% of health care budgets in many OECD countries. (CDC, 2009)

Goals:
The goal of Integral Process Design is to liberate sufficient resources due to operational optimization so that the entire construction and refurbishment budget for hospitals could be free of charge.

Avoiding dangerous assumption traps with IPD:
Today’s planning information is based on too optimistic efficacy assumptions which are not coherent with reality in hospitals. Planning has to be more realistic to avoid dangerous ‘Assumption Traps’ which lead to misdirected investments.

Tracing imposed inefficiencies with Grey Performance Analysis:
IPD focuses on externally imposed inefficiencies by targeting avoidable unnecessary work called ‘Grey Performance’.

Architectural consequences of IPD:
IPD significantly influences the organizational structure, functional layout and architectural planning of complex buildings. Health facility architecture must change its focus from optimal use of surfaces to optimal use of human resources.

Enabling more quality through additional revenues:
More revenues are possible by surrounding building design with business design already in the early project conceptualization.

Inhaltsverzeichnis (Table of Contents)

• PART A: OVERVIEW
• 1 INTEGRAL PROCESS DESIGN [IPD]: STUDY BACKGROUND AND SUMMARY
• BACKGROUND: Improved Planning and Operations for Complex Buildings
• SUMMARY: Integral Process Design [IPD]
• 2 INTEGRAL PROCESS DESIGN [IPD] FOR COMPLEX BUILDINGS
• 2.1 Mission statement
• 2.2 Problems of complex procedures : The airline example
• 2.3 Problems of complex procedures : The operating room (OR) example
• 2.3.1 What are the problems of complex structures in health care?
• 2.3.2 Conditions in the operating room
• 2.3.3 Assumption traps in the operating room
• 2.3.4 Management problems in the operating room
• 2.4 Integral Process Design response : The Berne OR-Cluster
• 2.4.1 Concept
• 2.4.2 Impact of the Berne OR Cluster
• 2.4.3 Outlook for Integral Process Design
• 2.5 Cost-free hospital investment: Eight statements for a new approach
• 2.6 SENIC study: successful implementation of study findings
• 2.7 From SENIC to IPD: quality improvements and cost reduction
• 2.7.1 How to approach the non-tangible: effective incentives for health care planning
• 2.7.2 Structure of Planning for complex buildings today
• 2.7.3 Goals of IPD : Embedding incentives in today’s structure
• 2.7.4 Today’s Paradigms in the planning of complex buildings
• 2.7.5 Today’s Lack in Strategic Options
• 2.8 Situation analysis summary of health facilities today
• 2.8.1 Performance problems in the running of health facilities
• 2.8.2 Sweet dreams of efficiency
• 2.8.3 The Assumption Trap in health facilities
• 2.8.4 Financial context summary of health facilities
• 2.8.5 Demotivating health care remuneration structures
• 2.8.6 Escaping the downward spiral: Introduction of small scale incentives
• 2.9 Challenges
• 2.9.1 Challenges in health care
• 2.9.2 Challenges in health facility operations
• 2.9.3 Challenges in planning
• 2.9.4 Challenges in implementation
• 2.9.5 From user talks to Transition Assistance
• 2.10 Complex building business case positioning
• 2.10.1 “Hospitals are accidents! They should not happen!”
• 2.10.2 “Hospitals are far too valuable to care only for ill people!”
• 2.11 INTEGRAL PROCESS DESIGN [IPD] : The concept
• 2.11.1 Function of IPD in the planning process
• 2.11.2 Structure and Components of IPD
• 2.11.3 Interface of IPD with the DRG medical service remuneration concept
• 2.11.4 Reversing the focus: From maximum use of space to maximum use of personnel
• 2.11.5 Unique Selling Points of IPD
• 2.11.6 The Market: Customers of IPD
• 2.11.7 Added Value
• 2.11.8 Implementation
• 2.11.9 Implementation of the IPD concept on a larger scale
• PART B: CONSTRAINTS
• 3 HEALTH FACILITY STRUCTURES : SHORTCOMINGS AND LIMITATIONS
• 3.1 The “time frame” problem of today’s health facilities
• 3.2 Lack of transparency during the planning of complex buildings
• 3.3 The mistakes of the “tailor-fit” solutions in today’s planning
• 3.4 Consequences of rigid focused plans: Lost flexibility
• 3.5 Reduced space occupancy and permanent service provision
• 3.6 Analysis: the limitations of today’s planning processes
• 3.7 Why do today’s health facilities seem to be outdated faster?
• 3.8 Strategic Space in hospitals
• 4 IMPACT OF HEALTH SERVICES FINANCING AND REMUNERATION
• 4.1 From Patient Classification Systems to Diagnostic Related Groups
• 4.2 ‘Fee-for-service’ remuneration : a major obstacle for efficacy
• 4.3 Separated budgets: a key problem for efficient planning
• 4.4 Hospital capital investment
• 4.4.1 Could hospital building investment be free of charge?
• 4.5 Current remuneration systems: “Disincentives” for doctors
• 4.6 Consolidation of separated investment and operational budgets
• 4.6.1 Monistic’ a model of unified health facility financing?
• 4.6.2 The Swiss TARMED catalogue and the German health fund.
• 4.6.3 The Dutch model of advanced DRG management.
• 4.6.3.1 From DRG to DTC: Combined hospital and external costs coverage
• 4.6.3.2 Yardstick competition: gradual adaptation towards higher efficiency
• 4.6.3.3 Consequences for the planning of health facilities
• 5 HEALTH FACILITY OPERATIONS : PROBLEMS TO ADDRESS
• 5.1 Assumption Trap: Working environment
• 5.2 Assumption Trap: Managerial structures
• 5.2.1 Potential and limitations of outsourcing: example maintenance
• 5.2.2 Outsourcing risks
• 5.2.3 Internal outsourcing: a win-win situation
• 5.3 Pitfalls within organizational concepts
• 5.4 Inherent inefficiency due to permanent service provision
• PART C: CONCEPT
• 6 CONCEPTS FOR THE PERFORMANCE MANAGEMENT IN HOSPITALS
• 6.1 Clinical Path Management [CPM]
• 6.1.1 Organizational improvements with Clincal Path Management
• 6.1.2 Lean Process Management in hospitals [LPM]
• 6.1.3 Pilot-study: Lean management at the University Center of Cardiology, Freiburg
• 6.1.4 Clinical Path Management: Conclusions
• 6.2 The OPIK project
• 6.2.1 Origin and background
• 6.2.2 Concept and goals of the OPIK model
• 6.2.3 The OPIK model: Conclusions
• 6.3 Evidence Based Design [EBD]
• 6.3.1 Origin and background
• 6.3.2 Concept and goals of Evidence Based Design
• 6.3.3 Applied tools of Evidence Based Design
• 6.3.4 Working with virtual patients to focus on the real needs
• 6.3.5 EBD focus: Improving the conditions for a healing process
• 6.3.6 Balancing one-time investment costs and operational costs with EBD
• 6.3.7 Evidence Based Design: Conclusions
• 6.4 The CORE-Hospital concept
• 6.4.1 Origin and concept
• 6.4.2 Goals and benefits of the CORE Hospital concept
• 6.4.3 The CORE Hospital concept: Conclusions
• 6.5 Outlook: A synthesis with Integral Process Design
• 7 IPD : AN APPLIED STRUCTURE FOR INNOVATIVE PLANNING IMPLEMENTATION AND EVALUATION
• 7.1 Approach and limitations in the case-oriented evaluation of this study
• 7.2 Embrace Plan
• 7.2.1 Today’s strategic limitations of the planning tools
• 7.2.2 Situation: master plans do not integrate business modeling
• 7.2.3 Benefits and shortcomings of today’s strategic planning tools
• 7.2.4 Definition and consideration of business criteria
• 7.2.5 Recent trends regarding the provision of basic planning information
• 7.2.6 Additional requirements for strategic planning
• 7.2.7 The integral hospital business plan: A ‘White spot’ in planning
• 7.2.8 Effective planning: Early detection, early response
• 7.2.9 Elements of an Embrace-Plan
• 7.3 Operational Flow Planning
• 7.3.1 Overcoming the provision gap: integrating unused resources
• 7.3.1.1 Making use of off-peak staff availability in accident & emergency
• 7.3.1.2 Coping with the provision gap at accident and emergency departments
• 7.3.1.3 Combining maternity and early rehabilitation
• 7.3.1.4 Provision gap and trends for patients’ length of stay
• 7.4 Healistic design: Quality and healing
• 7.4.1 Defintion of Healistic Design
• 7.4.2 Noise control and fear management with Healistic Design
• 7.4.3 Case in point noise control: Patients’ specific noise separation
• 7.4.4 Visual control with Healistic Design
• 7.4.5 Case in point visual control: Specific view control for patients
• 7.5 Grey Performance Analysis
• 7.5.1 Challenges: staff works hard but still is not efficient
• 7.5.2 Benefits: increased efficiency with Grey Performance Analysis
• 7.5.3 Approach: Structure of Grey Performance Analysis
• 7.5.4 Trend assessment of the cost saving potential with GPA
• 7.5.5 Grey Performance analysis: Operating department AOH-08
• 7.5.6 Return on Design assessment: Operating department AOH-08
• 7.6 Definition of Joker Areas
• 7.6.1 Joker Areas: Selection criteria for interfering with a complex system
• 7.6.2 Joker Areas: Economic and performance criteria
• 7.7 Business Modeling
• 7.7.1 IPD: Application of Business Modeling
• 7.8 Strategic Space Design
• 7.8.1 The lack of strategic spaces in today’s health facilities
• 7.8.2 The potential of strategic spaces in health facilities
• 7.8.3 Strategic Space Design: STEP 1 management of physical spaces
• 7.8.4 Strategic Space Design: STEP 2 management of healistic resources
• 7.8.5 Strategic Space Design: STEP 3 allocation management
• 7.8.6 Harmonizing the Anesthesia workflow
• 7.8.7 Transparency of wards versus longer ways (the Paris example)
• 7.9 Integration of additional business: The Joint Business Case
• 7.9.1 Hospital Care today: A monoculture business environment
• 7.9.2 Hospitals managed like airports: “And if your hospital was managed by Schiphol airport!”
• 7.9.3 Planning for complex buildings and the Joint Business Case
• 7.9.4 The Joint Business Case: An Economic Solidarity Model
• 7.9.5 The Joint Business Case: A Model for the Dongtan Eco Life City
• 7.9.6 The Joint Business Case: Elements and concept
• 7.9.7 The Joint Business Case: A model for Otto Wagner Hospital
• 7.10 Transition Assistance
• 7.10.1 Transition workshops and staff empowerment
• 7.10.2 The Klagenfurt resource model
• 7.10.3 Beating the assumption trap with continuous education
• PART D: IMPLEMENTATION
• 8 IPD : RETURN ON DESIGN
• 8.1 Benchmark criteria: Economic design validation with IPD
• 8.2 Scenario Planning with IPD
• 8.3 IPD: An instrument to manage the DRG transition
• 8.4 IPD: Economic and performance impacts of implemented IPD
• 8.5 IPD: Economic effects of an implemented Joint Business Case
• 8.5.1 Approach
• 8.5.2 Investment requirement
• 8.5.3 Consequences of the variants for the market position of [AOH-02]
• 8.6 Economic validation of health facility projects with IPD
• 9 IPD : MODERATING BUSINESS AND ARCHITECTURE
• 9.1 Challenges to design an efficient hospital.
• 9.2 From libertarian paternalism to over-regulation
• 9.2.1 Libertarian paternalism and the paradigm of free choice
• 9.2.2 Medical quality assurance and the trend for over-regulation
• 9.2.3 Visualizing process and design coherence
• 9.3 Creating a ‘choice architecture’
• 9.3.1 From guidelines to a choice architecture
• 9.3.2 Nudges for more efficient health facilities’
• 9.3.3 Design challenge: combining primary and secondary service excellence
• 9.3.4 Designing a loose-fit default concept
• 9.4 Default typology considerations
• 9.4.1 Modular building typologies
• 9.4.2 Allowing change with modular building elements in care
• 9.4.3 The ‘Vertical Embracement’ principle
• 9.4.4 The ‘Sandwich’ typology
• 9.4.5 Default ‘Sandwich’ layout recommendations
• 9.4.6 The ‘Slice’ concept
• 9.4.7 Clustering for optimal use of human resources
• 9.5 Default structural considerations GDHS (Grid / Depth / Height / Shape)
• 9.5.1 GDHS, [G]: The building grid
• 9.5.2 GDHS, [D]: The building depth
• 9.5.3 GDHS, [H]: The building height
• 9.5.4 GDHS, [S]: The building shape
• 9.6 Default organizational considerations
• 9.6.1 Design coherence: ‘Definitions to allow adaptability’
• 9.6.2 Team coherence: a challenge during long term projects
• 9.6.3 Decision coherence: ‘The golden rules’
• 9.7 The Moderation challenge
• 9.7.1 Achieving coherence within complexity: who is not at the table?
• 9.7.2 IPD early stage moderation for better use of human resources
• 9.8 Potential for further research
• 10 IPD : CONCLUSIONS AND OUTLOOK
• 10.1 Goals, characteristics and benefits of IPD
• 10.1.1 Integral Process Design: A toolbox for higher efficiency in complex buildings
• 10.1.2 Cost-neutral hospital investment: A real perspective or just a dream?
• 10.1.3 Cost-neutral hospital maintenance and refurbishment
• 10.1.4 Strategies to avoid the misdirection of IPD cost savings
• 10.1.5 Design coherence: A key factor for the success of IPD
• 10.2 Market for IPD: Clients and Added Value
• 10.3 Implementation strategies for IPD
• 10.4 IPD proposals for the design of complex buildings
• 10.5 Integral Process Design: Conclusions and outlook

Zielsetzung und Themenschwerpunkte (Objectives and Key Themes)

The main goal of this study is to present Integral Process Design (IPD) as a solution to address the growing issue of high healthcare costs in complex buildings, specifically hospitals. IPD aims to bridge the gap between business planning and building design, ensuring operational efficiency and cost-effectiveness from the early stages of planning. This approach focuses on the integration of operational processes and interdepartmental cooperation within a hospital, aiming to liberate sufficient resources for cost-free construction and refurbishment.

• Interdepartmental Cooperation and Efficiency: IPD emphasizes the importance of streamlining workflows between departments, minimizing inefficiencies, and maximizing resource utilization.
• Business Design Surrounding Building Design: IPD advocates for integrating business models and revenue strategies into the initial planning stages of hospital construction, ensuring long-term financial viability.
• Strategic Space Design: IPD emphasizes the need for strategic space planning within hospitals to accommodate future growth, expansion, and technological advancements.
• The Joint Business Case: IPD proposes the creation of a Joint Business Case for hospitals, incorporating additional revenue-generating activities like health-related tourism or wellness services to offset healthcare costs and create a sustainable model.
• Transition Assistance: IPD recognizes the importance of staff engagement and collaboration throughout the implementation process, including continuous education and empowering staff to contribute to the change.

Zusammenfassung der Kapitel (Chapter Summaries)

Part A: Overview

This part sets the stage by introducing the concept of Integral Process Design (IPD) and its application to complex buildings, particularly hospitals. It highlights the pressing issue of escalating healthcare costs and the need for efficiency improvements. The chapter explores the limitations of traditional planning methods and outlines the key goals of IPD.

Part B: Constraints

Part B delves into the constraints that hinder efficient planning and operation of healthcare facilities. It examines the shortcomings of current building structures, the limitations of "tailor-fit" solutions, and the negative impact of separated investment and operational budgets. This part also discusses the complexities of health service financing and remuneration systems.

Part C: Concept

Part C presents various concepts for performance management in hospitals, including Clinical Path Management, Lean Process Management, Evidence-Based Design, and the CORE Hospital concept. It explores their strengths and limitations, setting the stage for the introduction of IPD.

Part D: Implementation

Part D focuses on the practical application of IPD, showcasing its implementation in various hospital projects. It presents case studies, analyzes the economic and performance impacts of IPD, and outlines strategies for integrating business and architectural design. This part also delves into the crucial aspects of moderation, communication, and transition assistance for successful IPD implementation.

Schlüsselwörter (Keywords)

Integral Process Design, healthcare, hospital, efficiency, cost-reduction, business planning, building design, strategic space, Joint Business Case, transition assistance, operational excellence, grey performance, assumption trap, healistic design, sustainable planning, remuneration, DRG, DTC, monistic financing, healthcare system.

• College: Swiss Federal Institute of Technology Zurich (Department für Architektur)
• Author: Tom Guthknecht (Author)
• Publication Year: 2010
• Pages: 170
• Catalog Number: V283799
• ISBN (eBook): 9783656839811
• ISBN (Book): 9783656839828
• Language: English
• Tags: Embrace Plan, Healistic Design, Operational Flow Planning, Grey Performance, Strategic Space Design, Prospective Business Modelling, Joint Business Case, Transition Assistance, Performance, Efficiency, Flexibility, Incentives, Strategic Planning, health care financing, DRG, Remuneration systems, Design coherence, Economic Solidarity Model, Healing Environment, Interdepartmental cooperation, Nosocomial infection, infection risks, CORE Hospital, Operational Flow, Patient flow, Patient path, Clinical Path Management, Evidence based design, Patient focused care, Economical workflow