Shaping A New Organization

Valley View Medical Center, a small rural hospital in the fast-growing southwestern corner of Utah, exemplifies what Winston Churchill meant when he said of the built environment, "We shape our buildings; thereafter they shape us."

Valley View opened in 1963 as Iron City Hospital, in Cedar City, near Mt. Zion National Park. Over the next 20 or so years, the original owner's poorly planned additions and expansions turned the sprawling single-story medical center into a hodge-podge of disjointed departments and redundant services, with resulting inefficiencies and a bloated middle management.

"The building had isolated people in various corners and wings," says John Rich, VP of facilities development for Intermountain Health Care, Salt Lake City, which purchased the hospital in the 1980s and renamed it.

A situation like that might go unremarked in a large urban hospital, but rural hospitals like Valley View have to adjust to greatly fluctuating patient censuses, which often fall to minimum levels. As a result, administrators are forced to operate their facilities with a minimal staff of caregivers. In Valley View's case, there was no attempt by the first owners to operate in a way that considered whether a different operational system might be more suited to the facility's relatively small size.

In the early 1990s, as they deliberated whether to renovate or replace the hospital, IHC, which owns 22 healthcare facilities throughout the state, had to face up to the reality that the design of the 42-bed facility was more akin to that of a 200-bed urban hospital, says Andrew Mazurek, principal with healthcare programming and planning firm Metis Advisory Group Ltd., Rosemont, Ill. "The previous owner took the model for a larger hospital and shrunk it, and wondered why things didn't work."

What was needed, says Morgan Busch, director of community health systems development for IHC's rural region office, was "a facility that [would be] able to operate during busy times and slow times." To convert Valley View to maximum operational efficiency, IHC management realized, would require not only physical change, but a fundamental rethinking of its organization.

Replacement begets restructuring

For IHC's management, at least the first decision was easy. With the cost of renovation estimated to be 80% that of building a new facility, and with the surrounding community growing by 5% a year, IHC had no qualms about its decision to construct a $22 million, 113,000-gross-sf replacement medical center.

The next step was not so easy. IHC officials had to decide whether to keep the status quo and design a facility to fit its present organizational structure, or revamp the organization to fit a new model based on efficiencies to be reflected in the replacement medical center.

According to consultant Mazurek, most healthcare facility owners have neither the sophistication nor the stomach to implement deep organizational change. "Many administrators and hospital boards take the path of least resistance and go the safe route, doing it the same way they've done it for 40 years," he says.

IHC took the road less traveled and began focusing its attention on designing a medical center that would facilitate the restructuring of the organization, enabling Valley View to provide more patient-focused care while growing along with the community.

The public enters the medical center at two points: the main entrance and the emergency department.  The entrances serve as end points to the concourse.

IHC brought in Metis Advisory Group, which had previously programmed an IHC hospital in Salt Lake City, to develop a functional space program. The firm developed a series of concepts that forced IHC management to rethink how it operated. "A new replacement facility becomes an enabler for new behaviors for an organizational structure," says Metis's Mazurek. "It forces people to act differently." The organizational restructuring became the platform on which Houston-based architect Watkins Hamilton Ross (WHR), working in association with Salt Lake City-based Gillies Stransky Brems Smith as Mountain Health Design, based its design for the medical center.

The restructuring process hinged on identifying areas within the organization which had similar processes and exploring ways in which these processes could be combined in the new facility. "The objective was to make a more efficient organization with shorter lines of communication and at the same time design a building that consolidated more functions in specific areas," says IHC's Rich.

Of course, cost was a motivating factor in the owner's drive to create efficiencies, says Jon Hoopes, IHC's regional operations officer in charge of the project. "What's important to us at IHC is to provide the best service we can at the least amount of cost. The lower the cost, the more competitive and better off financially you are, now and in the future."

Designing for peak efficiencies

IHC then challenged WHR to design the organization efficiencies into the replacement structure. "The charge for us as architects was to be as efficient possible," says WHR principal D. Kirk Hamilton, FAIA, FACHA.

For example, net-to-gross ratios for room sizes in each department were to be kept as tight as possible. "They asked us to be on the absolute extreme edge in every single department, to leave no margin for sloppiness," says Hamilton. "Usually if you're tight in one area, you might be a little loose in another. So if you have trouble in one place, it averages out and you can make up the difference." On the Valley View job, though, "averaging" would not be tolerated.

For its part, WHR challenged IHC to remain committed to the restructuring process. When the hospital's administrator retired midway through the project, keeping IHC and the medical staff on course became Busch's responsibility. Throughout the project, as handoffs were made, Busch's role as "organizational memory" was to re-explain concepts for the restructuring and the rationale behind them. "Sometimes team members become uncomfortable with change and want to revert back to the way it was done before," says Busch. It was his job to make sure that didn't happen at the new Valley View, which opened on a new 23-acre site in February 2003.

Bringing departments together

Acting jointly, IHC, Metis, and Mountain Health Design whittled down the departmental structure of the organization. By combining adjacencies and like processes, the team was able to reduce the number of departments from 35 to 12. Instead of thinking of departments as "their own little professional domains," Mazurek says, the team organized processing activities into a convenient and optimal experience for the patient.

"The organizational changes were so dramatic that they couldn't have been made in the old building," says Hamilton. "There were too many barriers in the way the old building was configured, and the original organization of the physical structure would have impeded combining services in simpler ways."

Of all the organizational changes, surely the biggest hit with patients has been the new "routine diagnostics center." The "RDC" combines a number of the medical center's minor diagnostics services — blood tests, urine samples, x-rays, EKGs — into a one-stop department with a central reception and waiting area. Outpatients who used to have to find their way through the hospital maze no longer have to endure being bounced from one department to another. "That's the most frustrating thing to patients," says Mazurek. "The experience becomes a nightmare. You have to spit out the same information again at each stop. They ask you the same questions. You get lost. At the RDC, all of the services come to the patient."

With the new structure, outpatients complete their visits to the RDC in 10-15 minutes, says Valley View administrator Steve Smoot. Patients have given the RDC the highest patient satisfaction ratings at the new facility.

The management structure of the RDC also was simplified. "It's a huge improvement as far as patient comfort," says Dave Buller, director of ancillary services, who oversees the RDC. "There is less running around and more one-stop shopping. The adjacencies are good for managing the staff and for managing the patients."

Cross-training of technicians has been crucial to the success of the 18-person unit. Phlebotomists have been trained to perform routine imaging services like EKGs, while the imaging staff has been trained to draw blood. "It's more of a diagnostic center team concept, which has improved efficiency," says Buller. "Patients see fewer caregivers, and services can be performed more quickly."

Buller did add one full-time position to the RDC's staff to serve as "host," but instead of hiring an administrative person, the RDC's technicians rotate in and out of the position. Thus, in a pinch, the host also can draw blood or take an EKG. The host slot — a combination receptionist/customer service and go-to person for the rest of the technicians — has been "a key success factor" for the RDC, says Buller. Even with the added cost, "what you're really looking at is more bang for the buck in terms of the patient's perception of quality and service," he says.

Despite its success, the RDC has missed the mark in some areas of patient flow, says Buller. "We will continue to tweak the process as we grow," he says.

Planning for growth has been well conceived by the design team. For example, locating the diagnostic center next to the emergency department and designing the spaces so that each can be expanded into the other helps ensure the best use of both spaces and gives a brick-and-mortar structure what Busch calls "an accordion-like flexibility." At night, the 15-room emergency department can expand into the eight-room diagnostic center to accommodate peak volumes of patients.

Similarly, the pediatrics unit was rolled into the emergency department, because 40% of ER visits involve children. "In a small town, pediatrics is a problem because it's especially seasonal," says Mazurek. Beds fill up during the flu season, but otherwise pediatric beds go unused for much of the year.

Because the preparation, procedure, and post-anesthesia recovery processes are similar for outpatient surgery and endoscopy, the two departments have been combined into an ambulatory care center. This enables more efficient use of operating rooms and allows a single nursing staff to service all three areas, where two separate nursing staffs were required before.

The nursing staff is capable of juggling preparation, post-anesthesia, and surgical procedures simultaneously, says Debbie Esplin, R.N., Valley View's OR director. "Combining the populations of endoscopy and surgical services allows the nursing staff to take care of more patients than just the one or two endo patients," she says. "You can care for a couple of surgical patients along with endo patients."

To keep up with the increased volume of patients in the ambulatory care center, one full-time nurse and a working manager were added. "For long-term growth, it's a better utilization of staff," says Esplin.

Likewise, same-day surgery, which comprises 80% of surgical volume, has been located next to the OR area. "At the old facility, outpatient surgery was located at the end of the surgical hallway," says Esplin. "There was a lot of transporting back and forth."

Instead of a stand-alone building, the physicians’ clinic is attached to the medical center at its main concourse, enabling it to share the same waiting area as hospital services.

Not everything has been perfect. Locating the endoscopy area adjacent to recovery has resulted in recovery room patients and endoscopy patients crossing paths. "Typically, you don't want patients who are going into surgery seeing others that are coming out," says Esplin.

Another sore spot for the ambulatory center nursing staff is the location of central processing — the space where surgical supplies and sterile product are kept — in the basement beneath the ground-level OR area. Although the installation of a dumbwaiter has helped improve the transport of supplies and product to the OR, three full-time employees have been added to service the central processing area on a 24/7 basis. Esplin says she'd prefer to have central processing located at ground level near the OR area.

In the face of a surprisingly rapid increase in volume, though the number of full-time nursing staff in the medical-surgical department and intensive care unit of the medical center has not increased, more of the nurses are working more hours to maintain the 1:5 nurse-to-patient ratio, says nurse manager Kathy Caldwell, R.N. In its first nine months of operation, the 22-bed med-surg department and six-bed ICU reached capacity on 35 days. Although she expected higher volumes at the new facility, Caldwell says the departments "have reached this point faster than I thought we would."

Caldwell says that one reason for the higher volumes may be that, while the number of beds in the medical-surgical department, the birthing center, and the ICU is about the same as in the old facility, the rooms are now all private and include space for family members to stay overnight. To better enable caregivers to cover the larger area, the traditional nurses' station was decentralized and satellite workstations were installed for every four rooms. "Many of the caregiver functions are now located closer to the patient's bedside, so there isn't as much hiking back and forth for supplies, or to access information systems and locate medications," says WHR's Hamilton.

Every department in the facility is designed to be able to double in size as the community grows and volumes increase. "Each of the departments is designed to be independently expandable without jeopardizing any of the ongoing operations," says Hamilton. But rather than expand the ICU, many of the facility's ER physicians and surgeons would prefer to see the unit totally relocated nearer the ED. Because the ICU is located at the farthest end of the medical center from the ED and OR area, in emergencies "it's not as convenient as it could be for some of the physicians and surgeons," says Caldwell.

Hanging out the dirty laundry

When Valley View decided to outsource the laundry services to a laundry service 45 miles away in St. George, this seemingly innocuous decision rubbed many locals the wrong way, according to hospital administrator Smoot. "Looking at the cost of capital, having our own laundry facility didn't make sense," says Smoot. But Cedar City and St. George have been long-time rivals, and sending the dirty laundry to a St. George launderer touched off feelings that impaired relations between Valley View and Dixie Regional Medical Center, another IHC facility located in St. George that was building a new 108-bed facility at about the same time.

"They could have become symbiotic creatures," says Metis's Mazurek, with the larger Dixie Regional feeding supplies and services to the smaller Valley View. Proposals to link Valley View's materials and supply management support services, laboratory, and pharmacy to Dixie Regional failed to take off.

One area where efficiencies were achieved was in food service. Valley View's entrées and starches are cooked initially at Dixie Regional and then transported to Valley View, where they are transported and heated in mobile carts and served hot to the patient. "The system allows us to combine volumes so that we can cook with consistency and with less expense, which offsets the cost of transporting the food," says Smoot.

The organization efficiencies that the new facility has enabled Valley View to attain have helped the medical center become more efficient while holding down costs, says Smoot. "We would have had to increase our costs more had we not streamlined our organization," he says. "We doubled our capacity of the medical center, but we only increased our costs 10%, and half our costs are staff related."

The streamlining process enabled a number of managerial positions to be reduced, simplifying the organization and allowing those managers to assume more effective roles. But no one was laid off, says IHC's Rich. "In a growing community, you never have too many people, particularly in nursing."

The true value of the new facility will be realized in the coming years, says IHC's Busch. "The real gains will be in our ability to grow with the community without having to add as much staff."

Valley View: New vs. old